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  • Writer's pictureCare Interface

Social Determinants of Health Needs, Screening toolkit

The First Step in Your Social Needs Intervention

Health care leaders and front-line clinicians have long recognized the connection between unmet basic resource needs – e.g. food, housing, and transportation – and the health of their patients. Indeed, research suggests that more than 70% of health outcomes are attributable to the social and environmental factors that patients face outside of the clinic or hospital.

One of the first steps to addressing social needs is asking your patients about this aspect of their lives. Care Interface SDoH Screening Questionaire is derived from existing screening tools

(e.g. PRAPARE (Community Health Centers)

Bright Futures Questionnaire, Meaningful Use, Uniform Data Set (Community Health Centers), Accountable Health Community, Pregnancy Medical Home Screen, Health Leads standard SDoH Questionaire. This intentional alignment to existing tools will allow for easier implementation and similar data collection.

Essential Social Need Domains

Representing the most common social needs impacting the health of patients today, these domains are based on findings from IOM, CMS, and Health Leads’ two decades of experience implementing social needs programs. We recommend all healthcare systems include these domains in a screening tool for social determinants of health.

*Questions about financial resource strain often produce a high false positive rate; review these questions carefully.

*These categories will likely require a more highly skilled workforce than other types of social needs

Optional Social Need Domains

Depending on the goals of the initiative, these optional categories may be included on a social determinants of health screening tool.

*These categories will likely require a more highly skilled workforce than other types of social needs

Five Keys to a Great Screening Tool

Understanding a patient’s social needs can be challenging:

your patients may not speak or read English well, they may be concerned about divulging sensitive information such as immigration status, or they may have previously had negative experiences in attempting to address their social needs. So how do you ensure your screening process is patient-centered, while also achieving your population health research goals?

1. Make it short and simple

Patients have so many forms and questionnaires to complete when they visit a doctor these days, so we recommend that you keep your tool brief to ensure it is completed fully. We recommend your tool be:

  • Short, with a maximum of 12 questions

  • Written at a fifth grade reading level to accommodate low literacy populations

  • Translated into other languages, ideally those that are most prevalent in your clinics

Keeping your screening tool brief may be easier if you leave out benefits assessments or full intake questions. Follow the example of depression screening: your initial screening helps identify the potential need, while follow up questions with a clinician diagnose if the patient has depression and how to address it.

2. Choose clinically validated questions at the right level of precision

Identify targeted questions that match the need for your intervention and population. Watch out for broad questions that may generate false positives, narrow questions that do not catch enough patients, or questions that are relevant to specific patient demographics (e.g., pediatric or senior populations).

3. Integrate into clinical workflows

Social needs are part of a much larger patient journey and care plan. To successfully provide whole person care, we must expect providers to have the same understanding of patients’ social needs as they do of their clinical needs — and then equip them with the tools to act on what they hear from patients.

4. Ask patients to prioritize

Just because a patient screens positive for social needs doesn’t mean they would like help working on those needs. Talk to your patients about their priorities, goals, and strengths to clarify whether there are useful ways for your health system to provide support services.

5. Pilot before scaling

Given that there is no one standardized screening tool used by all health systems today, you may find yourself designing a tool that takes questions from multiple instruments. To confirm your screening tool is truly patient-centered, we recommend running a short evaluation to test the tool with patients before offering the tool to your entire patient population.

Recommended Screening Tool

Care Interface Social Determinants of Health Screening tool is adapted from over 12 screening questionnaires covering 5 key SOCIAL NEED DOMAINS 0) Socio-Demographic Information (Race & ethnicity, educational attainment, family income level, immigration status, languages spoken) 1) Food 2) Housing 3) Transportation 4) Interpersonal Violence or Exposure To Violence 5) Utility Needs 7 optional domains like: Childcare


Financial Resource Strain,

Behavioral/ Mental Health

Health Behaviors

Social Isolation & Supports Employment

  • Has been built on Behavioral science on the optimum reach out time, duration, medium and context to maximize the SDoH screening and capture

  • 38+ Languages

  • Low bandwidth access In the preferred Channel - sms or call

  • Conversational Engagement, linguistic and cultural competence

  • HIPAA compliant, Highly secure and end to end encrypted

  • Learning more about each individual and passing context to drive actions for CHWs and PCPs

Learn More about Care Interface Periodic SDoH Screening Platform by Scheduling a Demo

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