SDH: Tools & Resources

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 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 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

  • 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. 
  • 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.
  • 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.”
  • 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