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NCFH has created the Social Drivers of Health (SDOH) Resource Hub to increase awareness and knowledge of commonly used screening tools and to identify the SDOH factors that impact the Migratory and Seasonal Agricultural Worker (MSAW) population across the country.
The SDOH Resource Hub provides health centers (HCs) access to available screening tools, educational materials such as guides, fact sheets, infographics, videos and other resources related to the social factors that affect people’s health, to assist staff efforts in screening, documenting, and addressing SDOH factors impacting the MSAW population. This Hub also features screening tools and resources shared and discussed with participant HCs from NCFH’s IAC Plus Learning Collaborative (IAC PLUS LC), a HRSA supported collaboration intended to increase knowledge about SDOH factors impacting the health care, access, and health status of the MSAW population.
The SDOH Academy Compendium Resource is a collection of work produced by the SDOH Academy. This compendium includes SDOH webinars, micro-training modules, and showcases health center SDOH innovative practices. This resource is aimed at health centers and other organizations regardless of the stage of their SDOH response missions.
Social Drivers of Health (SDOH) are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and life outcomes and risks (Healthy People, 2030).
Watch this video, Social Drivers of Health - an Introduction, for more information about SDOH factors that impact population health outcomes. |
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SDOH can be grouped into 5 domains: Education Access and Quality, Health Care and Quality, Neighborhood and Built Environment, Social and Community Context, and Economic Stability. Click on each tab below to view SDOH resources per Domain.
Source: CDC
The connection of Education to health and wellbeing.
Childhood Education and Development
- Education as a Social Determinant of Health: a blog post developed by Tulane University School of Public Health and Tropical Medicine about education as a contribution to improve health outcomes of individuals and communities.
- Social Determinant Factors that Influence your Health - Education: An infographic created by The Nation’s Health about the connection between education and healthier people.
Language and Literacy
- Tool to Identify Indigenous Languages and Language Varieties from Mexico and Guatemala: This tool offers strategies to help community-based organizations, researchers, health centers, and public health officials identify the Indigenous languages and the language varieties spoken by Indigenous farmworkers from Mexico and Guatemala in each community to coordinate interpretation services, translation of resources, or collect information from diverse communities.
- Utilizing WhatsApp for Real-Time Language Interpretation on Agricultural Worksites: A tool designed and tested by NCFH staff using WhatsApp to interpret health education talks for farmworkers who speak Tzotzil and Spanish. Learn more about how it went and our tips for using this in the field.
- Language Competency Checklist: A tool created by NCFH to assess the competency of health center staff when providing interpretation services.
- Language Access Services Assessment and Planning Tool: A tool developed by NCFH to assist health centers in developing a plan to address language access needs and better serve patients needing such services.
- Assessing Bilingual Staff Competency Tool: This tool provides steps with tips and guidance for assessing the bilingual competency of health center staff to minimize language barriers in healthcare settings.
- Implementing a Language Access Program: A step-by-step guide developed by NCFH to implement Language Access Services (LAS) to patients with Limited English Proficiency (LEP).
- HHS - National Action Plan to Improve Health Literacy: A national action plan that envisions a restructuring of the ways we create and disseminate all types of health information to ensure that all children graduate with health literacy skills that will help them live healthier throughout their lifespan.
The connection between people’s access to and understanding of health services and their own health.
Access to Health Care
- Financial Responsibility Tool for Health Centers: a brochure developed by NCFH that provides information about the billing and payment process. It explains what patients may have to pay for health care services and how they can pay.
- Affordable Care Act (ACA) Factsheet: a resource developed by NCFH to help patients understand how to enroll in the ACA health insurance, become familiar with important words, learn about the enrollment process and important dates, and identify where they can find help and resources for them and their family.
Access to Primary Care
- Patient Telehealth Readiness Tool: a tool developed by NCFH to assist healthcare providers in identifying a patient’s willingness or need for resources and/or skills to engage in telehealth services.
- Health Tips - Patient Centered Health Home: publication by NCFH that focuses on health topics and issues prominent to the farmworker and the general Hispanic population. This issue talks about what a patient centered health home is and what you might experience in a health home during and after a visit.
- Hogar de Salud Centrado en el Paciente / Patient Centered Health Home: a digital story to inform the community about the unique features of a Patient Centered Health Home.
- Telehealth: What to know for your Family: A guide created by Coverage to Care (C2C), that shares the types of services, visits, and steps to prepare before, during and after using telehealth.
Health Literacy
- CLAS – Guide to Implementing Culturally and Linguistically Appropriate Services (CLAS): a set of action steps for providing CLAS and serve as a guide to promote healthcare organizations that fosters health equity for all patients regardless of their culture or socio-economic factors.
- CLAS – Organizational Self-Assessment: an assessment to help organizations recognize specific challenges, identify detailed strategies, and to set goals in meeting CLAS through the development of an implementation work plan with concrete tasks.
- CLAS – Implementation Template: a self-assessment that provides a snapshot highlighting the work you are currently doing and areas for growth to address CLAS.
- CLAS – Standards, Charts & Strategies: a set of guidelines to improve the quality of care and services for all patients, taking into account cultural health beliefs, preferred languages, health literacy levels, and communication needs.
- CLAS – Action Planning Template: an action template to list strategies and activities to address CLAS.
- A Guide to Developing Easy to Understand Materials for Any Audience: A guide developed by MHP Salud to improve the quality of informational written materials, increasing the understanding from a broader and more diverse audience of readers.
- Tips for Telehealth Communication: A tip and strategies sheet developed by NCFH to help healthcare providers improve communication with patients during telehealth encounters.
The connection between where a person lives – housing, neighborhood, and environment – and their health and wellbeing.
Access to Healthy Food
- Social Determinants of Health for Public Housing Residents Access to Healthy Food: A publication by the National Center for Health in Public Housing (NCHPH) and other national sources, that identifies the prevalence of social factors and population health indicators that affect public housing residents.
- Increasing Access to Healthy Food and Exercise in Public Housing Communities: A publication by the National Center for Health in Public Housing (NCHPH) and Public Housing Primary Care Grantees to explore strategies and programs that increased access to healthy food, exercise and weight control models.
- Food Rx Replication Guide For Health Centers: A publication by the National Center for Farmworker Health to help health centers implement their own Food Rx programs
Crime and Violence
- Addressing Violence In Public Housing Communities: A publication by the National Center for Health in Public Housing (NCHPH) focused on examples of violence prevention and intervention strategies in public housing communities.
- Healing-Centered Approaches to Screen and Intervene for Social Determinants of Health Including Intimate Partner Violence: A publication by Health Partners on IPV + Exploitation. This paper describes evidence-based strategies for responding to Intimate Partner Violence (IPV) – and offers an approach for healthcare providers and decision-makers that can also be applied to all efforts to address the social determinants of health.
Quality of Housing
- Guide for Safe and Adequate Housing for Agricultural Workers: A resource developed by the National Center for Farmworker Health to provide information about the types of agricultural worker housing across the U.S. and share specific recommendations and strategies for health centers, farmworker-serving organizations, agricultural employers, farm owners, and other farm worker advocates to reduce health risks and promote safe and healthy living environments for Migratory and Seasonal Ag Workers (MSAWs). Also available in Spanish.
- Housing and Health: A series of initiatives and resources developed by the Robert Wood Johnson Foundation for communities working to ensure access to safe, affordable housing for all.
- The Nation’s Health: Social Determinants Factors that Influence your Health: An infographic developed by The Nation’s Health addressing where and how people live, can influence how healthy they are and how well they live.
- Emergency Rental Assistance Call to Action Toolkit: a resource developed by the Consumer Financial Protection Bureau to provide stakeholders information on how to raise awareness about the rental assistance resources available to tenants and landlords.
- Housing, Health, and LGBTQIA+ Older Adults: A publication developed by the National LGBTQIA+ Health Education Center, Corporation for Supporting Housing, National Center for Equitable Care for Elders, and the National Health Care for the Homeless Council to provide promising practices for health centers supporting LGBTQIA+ older adults with their housing and related health care needs, including screening for homelessness and housing, supporting aging in place, providing affirming referrals for housing and supportive services, and offering inclusive health care environments.
- COVID-19 Informational Guide for Public Housing Residents – Know the Basics of Seeking Care, English & Spanish: A bilingual tool developed by the National Center for Health in Public Housing to provide general information on how public housing residents can seek care for COVID-19 testing services provided by health centers near public housing agencies and how the Public Charge rule does not apply for these services.
Workplace Conditions
- Health Enhancement Research Organization- Social Determinants of Health- an Employee Priority: A report created by Health Enhancement Research Organization (HERO) to identify and share best practices in the field of workplace health and well-being.
The connection between characteristics of the contexts within which people live, learn, work, and play, and their health and wellbeing.
Civic Participation
- Partnering with Legal Services to Address Social and Structural Issues that Impede Quality Health Care for Children and Adolescents: A tool developed by National Center for Medical Legal Partnership and School Based Health Alliance that provides information to address health services into school-based settings to ensure equitable access to healthcare for children and adolescents.
- Guide for Establishing Collaborative Relationships: a tool developed by National Center for Farmworker Health, Health Outreach Partners, and Farmworker Justice that provides information and resources to identify and develop community relationships that will help increase access to care for MSAWs by addressing SDOH that impact this vulnerable population.
- Resource Name: Increasing Capacity To Address Health, Justice, & Equity Through Partnerships: Description: A guide by health partners on intimate partner violence (IPV) + exploitation, to help health centers, domestic violence programs, & civil legal aid organizations address & prevent intimate partner violence, human trafficking, & exploitation
Health Equity
- Health Outreach Partners: Structural Competency: A Framework to Analyze and Address Social Determinants of Health and Health Disparities: A recorded on-demand webinar by Health Outreach Partners that introduces the Structural Competency framework and key concepts like structural violence and racism, and structural interventions. This webinar aims to provide you with the ability to discern how structures impact the health of patients and communities, and to allow participants to apply case studies relevant to health center programs.
- CDC: Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health: A workbook developed by the Centers for Disease Control and Prevention (CDC) and U.S Department of Health and Human Services, for public health practitioners and partners interested in addressing social determinants of health in order to promote health and achieve health equity.
Incarceration
- ReThink Health: Understanding the Impacts of Incarceration on Health: A framework created by ReThink Organization to develop a shared, high-level understanding of the systemic impacts of incarceration on health.
The connection between the financial resources people have – income, cost of living, and socioeconomic status – and their health.
Employment
- Health Action Council- Social Determinants Affecting Employment: UNTAPPED is a guide developed by Health Action Council, stating the different social determinants of health factors that affect employment and best practices on how employers can invest in an employee’s health, wellbeing, productivity and outcomes.
- Altarum Healthcare Value Hub- Social Determinants of Health: Food Insecurity in the United States: A research summary by Altarum Healthcare sharing the linkage between food insecurity, overall health, and health care costs, and features pathways policymakers and healthcare providers can use to increase access to nutritious food.
Poverty
- Social Determinants Factors that Influence your Health -Income: An infographic developed by The Nation’s Health, explaining how income can influence well-being and live expectancy.
SDOH Screening Tools and Resources
Screening for Social Drivers of Health (SDOH) can help identify specific population needs and identify who may benefit from resources and efforts to reduce health disparities.
This list contains screening tools and other resources, screening tools are denoted with an (*) asterisk for easy identification.
Screening for Social Drivers of Health (SDOH) can help identify specific population needs and identify who may benefit from resources and efforts to reduce health disparities.
This list contains screening tools and other resources, screening tools are denoted with an (*) asterisk for easy identification.
NCFH
NCFH has developed 3 tools to help health centers assess SDOH needs for agricultural worker populations and navigate health resources.
- (*) Patient SDOH Screening Tool: a set of questions for patients to evaluate their present situation and for health care teams to use this information to refer patients to available services.
- (*) SDOH Self-Assessment Tool: a tool to assess the current work of health centers in addressing SDOH.
- Increase Access to Care (IAC) PLUS Health Center SDOH Checklist: a checklist to identify Migrant and Seasonal Agricultural Workers (MSAWs) SDOH challenges, resources available, and strategies implemented to manage these barriers.
- (*) Increase Access to Care (IAC) PLUS SDOH Customizable Screening Tool: a tool to assist health care providers in assessing, screening, and documenting SDOH factors among MSAW patients and create an action plan to enhance population health outcomes and UDS reporting.
NACHC, AAPCHO, OPCA
Association of Asian Pacific Community Health Organizations (AAPCHO), and Oregon Primary Care Association (OPCA) developed this screening tool as a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health.
- (*) Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE) Assessment Tool: a standardized tool for collecting SDOH data to better serve diverse patient populations and capture unique factors that inform patient care and impact health outcomes.
- PRAPARE Implementation Action Toolkit: a toolkit focused on major steps to implement new data collection initiatives based on the experiences, best practices, and lessons learned of early adopting and pioneering health centers.
- (*) PRAPARE Readiness Assessment Tool: a tool to assess the organization’s readiness to implement the PRAPARE screening tool.
- PRAPARE Data Documentation and Codification: a spreadsheet with coding specifications and instructions for all PRAPARE measures that can be used to help develop internal PREPARE database that can integrate other clinic data sources.
- The Impact of COVID-19 on PRAPARE Social Determinants of Health Domains: an infographic providing information on how to identify those who may be most vulnerable during COVID-19 pandemic, prioritize patients in need of services, identify gaps and develop plans for addressing social risks in the community, and work to attain and maintain health equity.
- PRAPARE Infographic Fact Sheets: Multiple fact sheets that provide a high-level snapshot of PRAPARE and its development, use, and impact.
Centers for Medicare & Medicaid Services (CMS)
- (*) Accountable Health Communities Screening Tool : a tool to assess patients’ needs on housing, food security, transportation, and economic stability used to inform treatment plans and make referrals to community services.
- USING Z CODES: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes: This infographic describes the journey that social determinants of health (SDOH) data takes from the individual through the health system to data reporting as ICD-10-CM Z codes. It discusses data collection, documentation, coding and reporting and contains resources to help implement programs to collect and report SDOH data in a manner that can lead to better health outcomes for individuals.
EveryONE Project by American Academy of Family Physicians (AAFP)
- (*) Social Needs Screening Tool: a questionnaire for screening core health-related social needs, which include housing, food, transportation, utilities, and personal safety, using validated screening questions.
- Guide to Social Screening: a guide outlining the importance of screening for SDOH and the rationale for the questions included in the screening forms.
- Neighborhood Navigator: a website that allows users to search by zip code for resources and programs in their neighborhood to address SDOH. It provides information on food, housing, goods, transportation, health, care, education, employment, and more.
- Action Plan: a quick form to guide a discussion with your patients about their social determinants of health and document a plan to address them. The form is available in seven languages.
Health Begins
- (*) Upstream Risks Screening Tool & Guide: a questionnaire and guide developed by Health Begins Upstream Movement, based on the Institute of Medicine (IOM) recommendations to assess food, economic stability, social and community context, physical environment, and education.
BOSTON MEDICAL CENTER
- (*) WE CARE Survey: an instrument designed to identify social needs using self-report and a family-centered approach to determine a family's need for assistance.
HEALTH LEADS
(*) Social Needs Screening Toolkit: a comprehensive toolkit on screening patients for social needs based on recent guidelines from the Institute of Medicine (IOM) and Centers for Medicare & Medicaid Services (CMS) and the latest research available.
LOINC
- (*) WellRx Questionnaire: a questionnaire form to assess economic stability, education, neighborhood and physical environment, and food.
CORPORATION OF SUPPORTIVE HOUSING (CSH)
- Data Integration Best Practices for Health Centers & Homeless Services: a guide to support health centers in evaluating and making decisions regarding their SDOH data collection, utilization, and sharing to improve health outcomes for vulnerable populations.
AMERICAN HOSPITAL ASSOCIATION
- Screening for Social Needs: Guiding Care Teams to Engage Patients : a guide for healthcare leaders to engage their patients in SDOH screening conversations.
AVAILABLE National SDOH Services
- The SDOH Academy https://sdohacademy.com/
- Aunt Bertha (Findhelp): https://www.findhelp.org/
- 211: https://www.211.org/
- AAFP Neighborhood Navigator: https://navigator.aafp.org/
- Cap4Kids: http://cap4kids.org
- Feeding America: http://www.feedingamerica.org
- Supplemental Nutrition Assistance Program: http://www.fns.usda.gov/snap
- Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): http://www.fns.usda.gov/wic
- Public Housing and Voucher Program: http://www.hud.gov/topics/rental_assistance
The housing choice voucher program is the federal government's major program for assisting very low-income families, the elderly, and the disabled to afford decent, safe, and sanitary housing in the private market. Since housing assistance is provided on behalf of the family or individual, participants are able to find their own housing, including single-family homes, townhouses and apartments.
- Medical-Legal Partnerships: http://medical-legalpartnership.org
- Benefit Finder questionnaire: https://www.benefits.gov/
- 1Degree: https://www.1degree.org/
- NowPow: https://www.nowpow.com/