Social Needs Tools & Resources

A selection of tools and resources for health center 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.

Screening and Workflow Tools to Consider

Data Collection Tool

  • OPCA crosswalked ICD-10 Z codes and PRAPARE questions to help clinical teams add information from social screening to the problem list and EMR for claims and/or population health management.
  • PRAPARE Social Needs Data Dashboard Sample 

Tools & Resources for CHC-Community Partnerships

  • OHSU Richmond spotlight on Medical Legal Partnerships and Intimate Partner Violence programs 2019
  • 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.”
  • Reach Out and Read - "prescribe a book, change a life" - promotes early literacy and school readiness in primary care. The organization has an Oregon chapter
  • Oregon Food Bank  - 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. For materials tailored to your region, contact Lynn Knox, clinical outreach & training coordinator. 
  • 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.