Resources for Screening and Addressing Social Determinants of Health

This page contains tools, articles, and guides on screening for and addressing needs created by the Social Determinants of Health (SDOH). Visit the CHAMPS Social Determinants of Health Resources webpage for background on SDOH. These resources have been designed and selected to help health centers and Primary Care Associations offer culturally appropriate services to the populations they serve. Please contact the CHAMPS Programs Coordinator, Population Health if you have any questions about these materials or would like to share any other useful resources.

Please click or scroll down for:
Articles and Reports
Education and Training
Screening Resources
Addressing SDOH Resources
Other Resources


American Health Information Management Association (AHIMA)
Social Determinants of Health Data: Survey Results on the Collection, Integration, and Use
A study conducted by NORC at the University of Chicago which examines the operational realities of how social determinants of health data is collected, coded, and used in real-world healthcare scenarios. (2023)

American Journal of Preventive Medicine (AJPM)
Healthcare Sector Activities to Identify and Intervene on Social Risk
Introductory article to a special supplement included in the American Journal of Preventive Medicine which included nine research papers that highlight relevant categories of research on the healthcare sector’s social care-related activities. (2019)

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers
Study which evaluates patient and caregiver acceptability of social risk screening. (2019)

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers
Study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. (2019)

Social Determinants as a Preventive Service: U.S. Preventive Services Task Force Methods Considerations for Research
Brief review of the social determinants of health, the methods the U.S. Preventive Services Task Force uses to evaluate relevant evidence, and current evidence gaps for social risks. (2019)

Association of State and Territorial Health Officials (ASTHO)
A health equity metric assessment to strengthen the evidence base for measuring health equity by identifying and collecting known and emerging metrics that support health equity strategies and monitor advancements toward health equity. (2023)
Measuring Health Equity

BioMed Central (BMC)
Screening for Social Determinants of Health in Clinical Care: Moving from The Margins to the Mainstream
Article that delineates the contention and current relevance around whether or not to screen for social determinants of health in clinical care. (2018)

Journal of the American Board of Family Medicine (JABFM)
Do Patients Want Help Addressing Social Risks?
Article that analyzes differences between positive risks screens and desire for assistance. It explores possible explanations for those differences, focusing on the fallibility of screening tool, as well as patient preferences, priorities, and lived experiences, and the potential implications for health equity. (2020)

Journal of the American Medical Association (JAMA)
Assessment of Social Risk Factors and Interest in Receiving Health Care-Based Social Assistance Among Adult Patients and Adult Caregivers of Pediatric Patients
Investigative article which examines whether specific social factors are associated with patients interest in receiving health care-based social risk assessment. (2020)

National Data on Social Risk Screening Underscore the Need for Implementation Research
Commentary article that explores the extent to which social risk screening is conducted in clinical settings. (2019)

TimeDoc Health
The Role of SDOH Strategies in Population Health
Article that highlights the increasing importance of integrating SDOH into healthcare strategies to enhance population health. (2023)


Association of Asian Pacific Community Health Organizations (AAPCHO)
Identifying the Enabling Services Workforce for SDOH Screening and Documentation Webinar
Webinar that explores strategies to screen special and vulnerable populations for SDOH and build effective practices to begin addressing SDOH through Enabling Services. (2020)

Two Sides of the Same Coin: Addressing Social Determinants of Health and Enabling Services Data Collection – Webinar and Resources
Webinar about the ability of state Primary Care Associations (PCAs) to support the tracking and evaluation of non-clinical services and why it is an important tool in helping health centers to demonstrate their value in meeting and addressing patient social risks. (2020)

Association of Clinicians for the Underserved (ACU)
Addressing Race, Power, and Privilege in Clinical Settings Webinar
Webinar that offers frameworks and strategies to address issues around race, power, and privilege in clinical settings, with a focus on disrupting racism and improving clinical processes and outcomes. (2017)

Integrating SDOHs to Inform Collaborative Care: The FIU Models Webinar
Webinar on Florida International University’s collaborative care program for primary care and behavioral health that focuses on patients with depression, diabetes, and other chronic illnesses while integrating Social Determinants of Health (SDOHs). Interdisciplinary student teams and faculty work with community health workers to provide care and address SDOHs in underserved Miami communities. (2018)

Resources for Developing an Understanding of Health Disparities Webinar
Webinar that reviews online tools that offer both general and community-specific interactive learning activities to help primary care providers better understand the community and the challenges of their patients. (2017)

Center for Health Care Strategies (CHCS)
Addressing Social Determinants of Health: Connecting People with Complex Needs to Community Resources Webinar
Webinar that features speakers who shared strategies for addressing social determinants of health through screening approaches, innovative technologies that track social service referrals, and development of strong connections with community partners. (2018)

Farmworker Health Network (FHN)
SDOH Webinar Series
Three, one-hour webinars providing an overview of SDOH, barriers faced in addressing SDOH, and strategies used to overcome them. They also include presentations from actual CHC staff on the strategies they use to address these SDOH. (2019)

Health Begins
Webinars on topics such as understanding and addressing the political and legal determinants of health, the continued fight for health equity, upstream strategic thinking, and more.

Health Outreach Partners (HOP)
Structural Competency: A Framework to Analyze and Address Social Determinants of Health and Health Disparities Webinar
Webinar that introduces the Structural Competency Framework and key concepts like structural violence and racism, and structural interventions. This webinar aims to provide participants 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. (2020)

National Association of Community Health Centers (NACHC)
PRAPARE Trainings and Resources
Various trainings, resources, and reports regarding the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). (2017-2019)

Recorded PRAPARE Webinars
Presentations and webinars ranging from PRAPARE 101 to specific electronic health record template functionalities. (2017-2019)

National Center for Medical-Legal Partnership (NCMLP)
Health Center Medical-Legal Partnership (MLP) Toolkit Webinar Series
Five-part webinar series addressing the Health Center MLP Toolkit including information and resources to start, strengthen, and sustain medical-legal partnership. (2020-2021)

School-Based Health Alliance (SBHA)
Social Determinants of Health: Using Motivational Interviewing Strategies
Webinar focused on the use of Motivational Interviewing (MI) strategies when addressing social determinants of health affecting youth graduation rates. (2020)

Social Determinants of Health Academy
Breakthrough Series
Webinars during which SDOH Academy faculty helped participants “break through” the clutter to find the resources, experts, and peer linkages they need. (2021)

Foundational Trainings
Seven recorded trainings that lay the groundwork for health centers, Primary Care Associations (PCAs), and Health Center Controlled Networks (HCCNs) to integrate SDOH interventions into their care practices. (2018)


Association of Asian Pacific Community Health Organizations (AAPCHO)
PRAPARE Implementation and Action Toolkit
Toolkit designed to provide interested users with the resources, best practices, and lessons learned to guide implementation, data collection, and responses to social determinants of health needs.

American Academy of Family Physicians (AAFP)
EveryONE Project
Initiative that offers education and resources to help advocate for health equity, promote workforce diversity, and collaborate with other disciplines and organizations to reduce harmful disparities.

Social Determinants of Health: Guide to Social Needs Screening Tool and Resources
Guide to social determinants of health screening including introduction, information on team-based care and SDOH, short- and long-form SDOH screening tools, and more. (2019)

Center for Health Care Strategies, Inc. (CHCS)
Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations
Brief which examines how organizations are assessing and addressing SDOH for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care including selecting and implementing SDOH assessment tools, collecting patient-level information related to SDOH, creating workflows to track and address patient needs, identifying community resources, and tracking referrals. (2017)

Centers for Medicare & Medicaid Services (CMS)
Accountable Health Communities Model
Addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.

Health Leads
Health Leads Screening Toolkit
Comprehensive blueprint for health systems seeking to identify and screen patients for adverse social determinants of health. (2018)

National Academy of Medicine (NAM) Perspectives
Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool
Discussion paper exploring the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities Model Screening Tool. (2017)

National Association of Community Health Centers (NACHC)
Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
A guide to 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.

Oregon Primary Care Association (OPCA)
Social Needs Tools & Resources
Collection of tools and resources for health center use including information on Empathic Inquiry, sample workflows, community partnerships, and more.

Social Interventions Research & Evaluation Network (SIREN)
Social Needs Screening Tools Comparison Table (Pediatric Settings)
Table summarizing characteristics for each tool, including their intended population or setting, the social health domains they cover, and the number of questions covering each domain.


American Hospital Association (AHA)
Inspiration and Resources for Addressing the Social Determinants of Health
Compilation of resources to help practitioners address SDOH needs.

Centers for Disease Control and Prevention (CDC)
Tools for Putting Social Determinants of Health into Action
Tools and resources that can help practitioners take action to address SDOH.

Health Begins
Levels of SDOH Integration Framework
Standard framework for levels of integration for health-related social needs and social determinants of health. (2019)

Health Outreach Partners (HOP)
Social Determinants of Health: Addressing Access to Affordable and Nutritious Food for Underserved Populations
Article on the impact of malnutrition and tools for addressing access to affordable and nutritious food. (2014)

Taking Collective Action to Support Health Access: A Collaboration Toolkit for Community Health Organizations
Toolkit intended to provide the user with guidance and practical tools on engaging in collaborations to increase their collective impact. The toolkit is designed to include a broad application of the term collaboration, consisting of coalitions, partnerships, and referral networks. (2016)

Institute for Alternative Futures (IAF)
Community Health Centers Leveraging the Social Determinants of Health
Project that charts a path forward for the many health care providers who understand the importance of the SDOH for their patients’ health, but feel powerless to address their needs along non-medical dimensions. Based on a review of community health center (CHC) efforts in this domain, this report offers leaders in CHCs, public health, and policy an understanding of how health care providers can move beyond health care services alone to improve the health of the population. (2012)

Institute for Medicaid Innovation (IMI)
Value of Investing in Social Determinants of Health Toolkit
This toolkit is full of resources to articulate the business case for launching, leading, or expanding initiatives focused on inequities and social determinants of health. (2023)

National Center for Medical-Legal Partnership (NCMLP)
Bringing Lawyers onto the Health Center Care Team to Promote Patient & Community Health
Toolkit that provides the health center community with information and resources to start, strengthen, and sustain a medical-legal partnership (MLP). (2020)

How Legal Services Help the Health Care System Address Social Needs
Chart that shows some of the most common problems faced by vulnerable communities, and how legal expertise and services can help mitigate their negative impact on health and health care. (2015)

Where Legal Services Fit Within a Health Care Organization’s Response to SDOH
One-page fact sheet on how legal services can fit into SDOH response.

New York University (NYU) Langone Health
City Health Dashboard
A dashboard with data on 40 measures of health and drivers of health for more than 900 cities (and growing) across the U.S.


Association of Asian Pacific Community Health Organizations (AAPCHO)
Social Determinants of Health Resources

Cultural Competency Resources

Health Equity Resources

Health Literacy Resources

Social Determinants of Health Resources

Health Begins

Health Center Resource Clearinghouse: Social Determinants of Health

National Center for Medical-Legal Partnership (NCMLP)

Social Determinants of Health Academy

Social Interventions Research & Evaluation Network (SIREN)