Ready to take your first - or latest - step toward addressing SDH with your patients?
Here's a selection of tools and resources for health centers use.
Screening Tools & Resources
A growing number of health centers systematically screen patients for the non-clinical barriers that interfere with their patients' ability to lead healthy, productive lives. Some clinics screen their entire patient population, and others prefer to focus on a smaller subset of patients like those with uncontrolled chronic conditions.
Current SDH Efforts in Oregon CHCs
- In Winter 2018, OPCA interviewed 19 of our 32 CHCs to learn more about the variety of SDH efforts taking place in the health center setting, including population health equity, community health worker staffing, CCO relationships, and community partners. Read the final report here.
- In Fall 2017, OPCA conducted a survey to better understand what health centers around the state were doing to screen patients for their social determinants of health, what challenges health centers face, and what data is being used for. Read the final report here.
Screening and Workflow
- OPCA has developed 4 workflow alternatives to help clinical team members screen patients for SDH; they include:
- OPCA drafted an ICD-10 and Z code crosswalk to help clinical teams add information from social screening to the problem list and EMR for claims and/or population health management.
- In partnership with the NACHC and AAPCHO, OPCA has developed a screening tool - Protocol for Responding to and Assessing Patients' Assets, Risks and Experiences (PRAPARE) - to use in learning more about a patient’s context. Located here are the PDF versions of the latest tool (last update September 2016) in English and Spanish. Click here to learn more about the toolkit and resources available for the tool.
- In 2014, the Institute of Medicine (IOM) recommended that 12 social determinants be included in all electronic health records as part of Meaningful Use 3. Click here to access the full report.
Food Insecurity Tools & Resouces
- Check out OPCA’s July 2017 report on our 9-month food insecurity learning collaborative. 3 Oregon CHC’s screened for and intervened on food insecurity to improve population health.
- The Oregon Food Bank partners with clinics and health systems to implement a validated two-question food security screening questionnaire. They provide options for assisting food insecure patients with connections to local food and nutrition resources through multilingual tools that can be integrated into your electronic health record. Sample materials include screening questions and a resource list. For materials tailored to your region, contact Lynn Knox, 503-853-8732, clinical outreach & training coordinator. Lynn can also provide other assistance.
- Partners for a Hunger-Free Oregon is a statewide organization that works with communities to end hunger before it begins. They provide resources, technical assistance for medical providers, and educational opportunities.
- Good and Cheap: Eat Well on $4/Day provides a free PDF cookbook for people on very tight budgets. Recipes are free to distribute. The organization plans to release a free Spanish version in 2015.
- The Institute of Medicine recommends a single-question food insufficiency screening survey: “Which of the following describes the amount of food your household has to eat: enough to eat, sometimes not enough to eat, often not enough to eat.” See page 152 of the full report for more information.
Housing Insecurity Tools & Resources
- The U.S. Veterans Administration uses a brief screening questionnaire to assess homelessness and housing instability.
- The National Health Care for the Homeless Council offers a wealth of resources and trainings.
- SeaMar Community Health Center has a screening tool that asks a number of housing-related questions. Housing-related problems account for five of the top 12 needs of SeaMar patients and represent 27 percent of total responses.
Tools & Resources to Integrate SDoH into Clinical Care
- Caring with Compassion offers a curriculum to educate clinicians on using team-based skills and biopsychosocial models of care to provide personalized care for at-risk patients.
- The Association of Academic Health Centers provides a toolkit to promote multisectoral collaboration to address the social determinants.
- Unnatural Causes is a seven-part documentary series exploring racial and socioeconomic inequalities in health. Includes a discussion guide and action toolkit.
- Clinical Directors Network archived webcast, "Upstreamists & Community Health Detailing: How Re-Imagined Workforce and Community Engagement Models Can Improve Healthcare and the Social Determinants of Health."
Tools & Resources for CHC-Community Partnerships
- Medical-Legal Partnerships integrates legal care into primary care to improve health. As the website notes, "Many of [the social determinants] can be traced to laws that are unfairly applied or under-enforced, often leading to the improper denial of services and benefits that are designed to help vulnerable people.”