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The Aunt Bertha application allows users to connect and refer patients to free or reduced-cost need-based social services in order to proactively address SDoH factors. Users can easily find local social service programs for a patient by launching the Aunt Bertha web application. In addition to searching for programs, users can make referrals for patients, track referral outcomes, document patient's goals, and view reports of search, referral, and community organization activity. Users can complete assessments to support automatic program recommendations, as well as Accountable Health Communities and Comprehensive Primary Care+ projects. In addition, users can also see which programs have claimed their Aunt Bertha listing, and can close the loop on referrals as they work with patients directly. They can even direct patients to their own community-facing Aunt Bertha site so patients can self-navigate and self-refer to services.