Category: Resource

Prior to COVID-19, health care investments in SDOH programs to support connecting patients to community resources were on the rise, supported by a proliferation of technology solutions like Aunt Bertha, Unite Us, NowPow and others. These resource databases serve as critical tools for tracking the local services landscape and connecting people to the essential resources they need to be healthy (Cartier et al. 2019). However, when adopting these technology solutions to support SDOH programs, it is important to recognize that more resource information does not always result in people being connected to resources. There are best practices for managing resource information, and using and interpreting the data to effectively and equitably connect people to resources. Here, we aim to provide examples to demonstrate the ways in which data usage and interpretation can impact equitable access to essential resources and improve connection rates.

This report updates the 2017 data highlight on Z code claims for Medicare fee-for-service (FFS) beneficiaries. Using social determinants of health (SDOH) Z codes can enhance quality improvement activities, track factors that influence people’s health, and provide further insight into existing health inequities. The report describes Z code claim data collected from 2016-2019 and highlights potential strategies to increase Z code utilization in reducing health care disparities.

Technology solutions connecting health and social care services. (Acquired NowPow and Carrot Health in 2021).

Aunt Bertha’s network connects people seeking help with social needs and Search and connect to support. Financial assistance, food pantries, medical care, and other free or reduced-cost help starts here at FindHelp.

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.