Author: IPRO

The Social Needs Screening tool screens for five core health-related social needs, which include housing, food, transportation, utilities, and personal safety, using validated screening questions, as well as the additional needs of employment, education, child care, and financial strain.

The revised Social Needs Screening Toolkit combines Health Leads’ 20+ years of experience implementing social needs programs with well researched, clinically-validated guidelines from sector authorities like the Institute of Medicine, Centers for Medicare and Medicaid Services and the Centers for Disease Control & Prevention — all in a single how-to guide.

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is 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. As providers are increasingly held accountable for reaching population health goals while reducing costs, it is important that they have tools and strategies to identify the upstream socioeconomic drivers of poor outcomes and higher costs.

The PRAPARE Screening Tool has been translated in over 30 languages. Use this link to locate a non English version.

The PRAPARE Screening Tool

This HHS website features information, continuing education opportunities, resources, and more for health and health care professionals to learn about culturally and linguistically appropriate services, or CLAS.

This tool helps hospitals to capture data on the social needs of their patient population using ICD-10-CM codes included in categories Z55-Z65 (“Z codes”), which identify non-medical factors that may influence a patient’s health status.

The Gravity Project is a national public collaborative that develops consensus-based data standards to improve how we use and share information on social determinants of health.

This online course by the CMS Office of Minority Health offers solutions for increasing the physical accessibility of health care settings and services for people with disabilities. This is an online course on the Medicare Learning Network (MLN).

Social Isolation and Loneliness in Older Adults summarizes the evidence base and explores how social isolation and loneliness affect health and quality of life in adults aged 50 and older, particularly among low income, underserved, and vulnerable populations. This report makes recommendations specifically for clinical settings of health care to identify those who suffer the resultant negative health impacts of social isolation and loneliness and target interventions to improve their social conditions.

The Healthy People 2030 webpage on has useful information on social determinants of health (SDOH) including the widely-used definition and graphic that explains, “What are social determinates of health?” There is also information on how the Healthy People 2030 campaign and other organizations are addressing SDOHs.

The AHA is working to support hospitals and health systems as they address social determinants of health, eliminate health care disparities and provide comprehensive care to every patient in every community—all of which improve community health. The AHA is continuously developing resources on how hospitals can address the social determinants of health in their communities. The website includes reports, case studies, webinars and videos on eight social determinants of health.

The Resources Inventory from the CMS Office of Minority Health is a catalog of diabetes prevention resources tailored to various audiences, including racial and ethnic minorities, LGBTQ communities, people with disabilities, and people with limited English proficiency.

This document is intended to provide recommendations on how to improve accessibility in order to improve quality of care for patients with disabilities. It includes guidance on how to increase physical accessibility of medical services, tools to assess a practice or facility’s accessibility for individuals with disabilities, and tips and training materials to support efforts to reduce barriers and improve quality of care.

This mini self-assessment is designed to support nursing homes in assessing current QAPI structure, data utilization, and performance improvement projects and establishing next priorities for continuous improvement.