Metrics, Measures, and Instruments

We’ve gathered some of the available metrics, measures, and instruments relevant to research on screening and addressing social needs in health care settings. To the extent information is available to us, along with the actual instrument we provide a brief summary about where and when the tool has been used and links to any existing evidence about it.

Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways

Pathways Community HUB InstituteCommunity Care Coordination Learning Network
Once a community care coordinator (CCC) completes a comprehensive assessment of health, social, behavioral health, economic, and other factors that place the individual at increased risk the Pathway tool is used to confirm that interventions have been received by the individual and that identified...

WellRx ToolKit

Janet Page-Reeves, PhDMolly Bleecker, MA
A validated 11-item questionnaire designed to be utilized at every patient visit, covering the domains of food insecurity, housing, utilities, income, employment, transportation, education, substance abuse, child care, safety, and abuse. Questions conform to “low literacy”. The questionnaire is...

IOM Recommended Social and Behavioral Domains and Measures for Electronic Health Records

Committee on Recommended Social & Behavioral Domains & Measures for Electronic Health Records
Determinants of health—like physical activity levels and living conditions—have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs...

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

NACHCAssociation of Asian Pacific CHOsOregon Primary Care AssociationInstitute for Alternative Futures
The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) was developed by NACHC and partners to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. The PRAPARE...

Health Leads Social Needs Screening Toolkit

Health Leads
Drawing on Health Leads' experience and recent federal guidelines, this toolkit provides screening best practices, a questions library, and a sample recommended screening tool for some of the most common unmet social needs: food insecurity, housing instability, utility needs, financial resource...

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

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

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...

Medical-Legal Partnership Screening Guide

National Center for Medical-Legal PartnershipsThe Advisory Board Company
The National Center for Medical-Legal Partnership, with pro bono support from The Advisory Board Company, reviewed 80 tools used by medical-legal partnerships across the country to screen for patients’ legal need and then developed a common screening tool that can be used by hospitals and health...

IHELP Pediatric Social History Tool

IHELP is a screening tool used in pediatric settings, based on previous work by by Kenyon et. al. in 2007, that explores 8 domains of social needs: income, insurance, hunger, housing conditions, homelessness risk, child educational needs, domestic violence, legal status, and power of attorney/...


WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based screening and referral system developed for pediatric settings. The 12-question WE CARE screening tool assesses needs in 6 domains: parental educational attainment, employment, child care,...