Communities across the globe have faced significant challenges due to widespread economic stability, strained healthcare systems and growing health disparities. Community service providers report steady increases in calls for resources—such as food, housing, and transportation—placing additional strain on health systems. There is a critical need to identify how to overcome barriers to accessing community services, particularly for individuals with limited resources. Our program of research has successfully leveraged existing, low-cost technology to conduct social needs screening during emergency department (ED) care, followed by referral through United Way 211’s community service system and data exchange between platforms. This approach shows promise for understanding and meeting the needs of patients with unmet social needs during the pandemic. Findings from a recent sample of approximately 5,000 patients screened during ED visits, along with qualitative data from service providers, 211 specialists, ED staff, and patients, indicate that effectively addressing social needs requires targeted strategies to build trust and facilitate outreach. Using a pragmatic trial approach in a sample of 1,500 patients screened for social needs at ED, clinic, and mobile care sites, this real-world efficacy (NIH Stage 3) study aims to determine whether use of community services improves health outcomes, and whether random assignment to intensive follow-up and collaborative goal setting increases service utilization. We hypothesize that patients who use community services to meet social needs—defined as needs related to transportation, food, utilities, and medical expenses—will experience improved health outcomes, and that those engaged in collaborative goal setting with a 211 specialist will be more likely to access services. Understanding how to address the social, mental, and physical effects of economic hardship is essential to reducing health disparities and strengthening the capacity of health systems to respond to community needs.