Implementation Resources

Below are guides, toolkits, and reports that provide recommendations and guidance about how to implement social needs screening and interventions in clinical settings. Additional information to inform implementation efforts, including peer-reviewed research articles, can also be found in our Evidence Library.

Compendium of Medical Terminology Codes for Social Risk Factors

2018
A. Arons, S. DeSilvey, C. Fichtenberg, & L. Gottlieb
This spreadsheet contains codes related to social risk factors that we extracted in a systematic search of four medical vocabularies ( LOINC, SNOMED CT, ICD-10-CM, and CPT) . The spreadsheet is intended to help interested stakeholders (including from clinical and social service providers, measure...

HealthBegins Webinar: Designing and Financing Sustainable Community Health Investments

2018
Rishi Manchanda, MD, MPHJason HelgersonBill Pinakiewicz
National experts describe operational and financing strategies and best practices to establish sustainable partnerships with community organizations. Watch now .

Social Determinants of Health Series: Transportation and the Role of Hospitals

2017
Health Research & Educational Trust
This guide explains the link between transportation and health and discusses the role of hospitals and health systems in addressing transportation issues, improving access and helping design and support better transportation options. Although hospitals and health systems traditionally have not...

Social Determinants of Health Series: Food insecurity and the role of hospitals

2017
Health Research & Educational Trust
This guide discusses the link between food insecurity and health issues, including chronic illness and child development, and the role of hospitals in identifying food-insecure individuals and households to help address this determinant of health. Access the Guide >

Social Determinants of Health Series: Housing and the role of hospitals

2017
Health Research & Educational Trust
This guide is the second guide in a series of resources from the Health Research & Educational Trust (HRET) and Association for Community Health Improvement (ACHI) on how hospitals can address the social determinants of health— such as adequate housing, quality education and access to...

Screening for social determinants of health in populations with complex needs: implementation considerations

2017
C. Thomas-HenkelM. Schulman
Compared to other industrialized nations, the United States spends disproportionately less on social services, and more on health care. This is true despite evidence that social determinants of health (SDOH) — including income, educational attainment, employment status, and access to food and...

Connecting those at risk to care: the quick start guide to developing community care coordination pathways

2016
Pathways Community HUB InstituteCommunity Care Coordination Learning Network
This Quick Start guide complements Pathways Community HUB Manual: A Guide To Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes, initially published in 2010 by the Agency for Healthcare Research and Quality (AHRQ). The publication provides a detailed overview of the Pathways...

Screening and interventions for food insecurity in health care settings state strategies to increase an underutilized practice in California

2016
M. Cannon
Despite a growing body of evidence suggesting that food insecurity has significant consequences for the health of low-income Californians, very few hospitals and health clinics in our state are routinely screening for food insecurity. In this paper we examine how food insecurity screening tools can...

The Hunger Vital Sign: Best practices for screening and intervening to alleviate food insecurity

2016
Rebecca RottapelRichard Sheward
The Hunger Vital Sign(TM) (HVS) is a validated 2-question food insecurity screening tool that allows clinicians to accurately identify households at risk of food insecurity and address patient needs appropriately. Endorsed by the American Academy of Pediatrics, the tool is being used by hundreds of...

Addressing Food Insecurity: A Toolkit for Pediatricians

2017
American Academy of PediatricsFood Research & Action Center
Developed by the American Academy of Pediatrics (AAP) and the Food Research & Action Center (FRAC), this toolkit was created to aid pediatricians in addressing patient food insecurity. It provides information about the prevalence of food insecurity, how food insecurity impacts children's health...