Social conditions in which we live may be a greater predictor of life expectancy and cancer risk and prognosis than other factors traditionally discussed. Failure to obtain screening information regarding social determinants of health can no longer be considered acceptable. This application’s goal is to optimize screening methodology and coordination of patient assistance programs in the community. We will address the fundamental causes of health inequities with a screening and intervention program in collaboration with community partners, Stephenson NCI Designated Cancer Center (SCC) and community cancer centers in both urban and rural sites. The successful collaboration of Parkland, PCCI and Pieces in Dallas is intended to be replicated and the IT software operationalized to all sites in Oklahoma and then it should be generalized to NCORP sites across the country. The team will pilot test the software and evaluate its ease of use for stakeholders including medical care and community service providers, cancer patients, social workers, patient navigators and administrators. The EMR will be updated to include the social needs in the problem list and referrals for services requested (and if services are successfully obtained). Each stakeholder will recommend quality improvements and continue improvement cycles until the processes are optimized.