SDOH & Practice Improvement

Tools to Help Healthcare Organizations Address SDOH

AHRQ is actively engaged in assisting health systems and clinicians to improve healthcare through a better understanding of SDOH in communities and the social needs of patients. Health systems can benefit by understanding the social determinants in the communities in which their patients live. In addition to giving them insights into the lived experiences of their patients, health systems that learn about the SDOH of the communities they serve may become inspired to engage in community-level efforts to address those SDOH, such as establishing farmers markets in food deserts, safe exercise space, or affordable housing.

Learn about Federal sources of data that can inform health systems about the community context.

Assessing Patient Social Risks and Needs

There are numerous tools to help identify social needs patients currently have and their risks for developing social needs. For example, AHRQ-funded researchers studied how six organizations developed and tested screening tools for social needs of their patients. Access a published article on the results, "How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care".

Below are the five screening tools they studied that are still in use:

• HealthBegins Upstream Risks Screening Tool (PDF) includes questions about 14 SDOH. 
• WellRx is a validated 11-item clinical screener for nonmedical social needs.
• Kaiser Permanente's Your Current Life Situation (YCLS) survey (PDF) captures a range of social and economic needs, including living situation, housing, food, utilities, childcare, debts, medical needs, transportation, stress, and social isolation.
• Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) (PDF) includes 17 core questions and 4 optional questions about SDOH. Its implementation guide includes the four electronic health record (EHR) tools, technical resources, best practices, multiple tested workflows, and other resources.
• OCHIN’s EHR-based SDOH Data Collection, Summary, and Referral Tools (PDF).

The U.S. Preventive Services Task Force recommends screening for some social determinants. Developing Primary Care-Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force highlights social determinants already recommended and proposes a process by which other social determinants may be considered for primary care preventive recommendations.

AHRQ Resources to Address SDOH and Social Needs

Clinical-community linkages help to connect healthcare providers, community organizations, and public health agencies so they can improve patients' access to preventive and chronic care services. The goals of clinical-community linkages include:

• Coordinating healthcare delivery, public health, and community-based activities to promote healthy behavior.
• Forming partnerships and relationships among clinical, community, and public health organizations to fill gaps in needed services.
• Promoting patient, family, and community involvement in strategic planning and improvement activities.

Learn about AHRQ’s tools and resources on forming clinical-community linkages.

Learn about AHRQ’s tools and resources on care coordination.

Learn about AHRQ’s tools and resources for delivering culturally and linguistically competent care.

Learn about AHRQ’s tools and resources for delivering health literate care.

Learn about a tool to help primary care practices screen and refer patients for social needs such as food or housing.