Social Determinants of Health Tools

May 06, 2024


Tools To Measure SDoH | A Closer Look

As we’ve established, there’s a heightened focus on understanding and addressing social determinants of health (SDOH). Screening tools and surveys, new and existing, have emerged as essential instruments in  enabling healthcare providers to identify and mitigate factors influencing patient outcomes. The healthcare industry has made significant strides in recent decades in developing and validating screening tools across various disciplines. Now, similar tools are emerging to address the complex landscape of SDOH.

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SDOH Screening Tools

AHC Health-Related Social Needs Screening Tool

The CMS The Accountable Health Communities Model (AHC) initiative introduces the Health-Related Social Needs (HRSN) Screening Tool, designed to systematically identify and address social determinants of health (SDOH) among Medicare and Medicaid beneficiaries. Developed by the CMS Center for Medicare and Medicaid Innovation (CMMI), this tool aims to assess the impact of addressing health-related social needs on healthcare costs and outcomes. The screening tool encompasses ten core domains, including housing instability, food insecurity, transportation issues, utility needs, and interpersonal safety, with additional questions covering financial strain, employment status, family and community support, education, physical activity, substance use, mental health, and disabilities. Hospitals are encouraged to utilize this tool to gauge patients’ social needs, supporting the AHC initiative’s objective of promoting health equity and improving health outcomes.

It’s important to note that CMS does not mandate the use of this tool, providing hospitals with flexibility to collect SDoH information in whatever way is most efficient for them.

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences | PRAPARE

PRAPARE is a national standardized patient risk assessment tool designed to engage patients in evaluating and addressing social drivers of health. Featuring 21 SDOH domains, PRAPARE® scores range from 0 to 22, with 0 indicating no reported risks and 22 indicating all measured risks. Additionally, the tool has been translated into over 25 languages, enhancing accessibility for diverse populations.

Health Begins Upstream Risks Screening Tool

This free screening tool comprises 28 questions distributed across 5 domains: economic stability, education, social & community context, neighborhood & physical environment, and food. Notably, the tool has an 11th grade reading level. “Addressing social determinants of health at a federally qualified health center” marks its first application in real-world healthcare settings.

    people in a clinic waiting room

    More SDOH Screening Tool Options 

    While tools like PRAPARE and the Health Begins Upstream Risks Screening Tool offer valuable insights, they represent just a fraction of the available resources. For a more comprehensive list and detailed comparisons, the SIREN team at UCSF has compiled content from various widely used screening tools. This resource equips healthcare providers with the information needed to select the most suitable tool for their practice or organization’s needs, ensuring effective screening and intervention strategies. Visit the UCSF SIREN website to explore the full spectrum of screening tools and their characteristics.

    Building SDOH Data Standards 

    As patient-reported information broadens to encompass social needs, demographics, and health status, there’s a growing need for standards supporting the exchange of screening results. The Gravity Project, an HL7 FHIR accelerator, has developed the FHIR SDOH Clinical Care Implementation Guide to address this need. This guide profiles FHIR Questionnaire and Questionnaire Response, facilitating the calculation of responses to multiple screening questions, aligning with the common practice of deriving scores from a panel of questions in SDOH instruments and PROMs. Adoption of these profiles by HL7 and Office of the National Coordinator for Health Information Technology (ONC) could bolster the adoption of social needs screening and interventions, enhancing quality and equity in healthcare.

    In closing, these SDOH tools are positioned to become foundational in quantifying population health and individualizing patient care, offering a direct line to understanding patient needs and shaping interventions. As we anticipate the emergence of even more patient-reported tools surrounding social domains, it’s clear that these resources are shaping the industry’s approach to better understanding population health and ensuring equitable care.

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