Guide to Implementing Social Risk Screening and Referral-making

This guide was developed by teams at the Kaiser Permanente Center for Health Research and OCHIN, Inc as part of an NIH-funded study (1R18DK114701). The purpose of this study was to test the effectiveness of targeted implementation support at enhancing social risk screening adoption in primary care settings and community health centers.


Adverse social determinants of health – referred to in this guide as social risks – include contextual factors such as food, transportation, and housing instability, and social isolation. Collecting information on these risks can help ambulatory care teams understand and address how these factors impact their patients’ health.

This pragmatic guide will help your clinic implement social risk screening and (if desired) referral-making, or improve your current practices. It is meant to be used by any primary / ambulatory care staff interested in implementing social risk screening and referral-making.


This guide uses a five-step roadmap for implementing or improving social risk screening and related activities at your clinic. It provides tools and materials to support each step, and a list of useful resources.

Introduction [PDF]

Step 1: Getting Ready [PDF]

Step 2: Identify Clinic Goals [PDF]

Step 3: Create a Social Risk Plan [PDF]

  • Social Risk Screening and Data Collection Workflow Planning Tool [Excel]
  • Social Risk Screening Workflow Rollout Planning Tool [Excel]

Step 4: Orient Clinic Staff To Your Clinic’s Social Risk Plan [PDF]

  • Social Risk Screening Kick-Off / Staff Orientation Slide Deck [PowerPoint]

     Kick-off Package

  • Social Risk Screening Kick-Off Meeting Agenda [Word]
  • Goals Thermometer [Excel]
  • Certificate of Recognition [Word]
  • Social Risk Screening Poster[PDF]
  • Social Risk Screening Poster [PowerPoint]

Step 5: Roll Out and Iterate [PDF]

Resources to Support Implementing Social Risk Data Collection and Referral-making [PDF]

Guide to Implementing Social Risk Screening and Referral-making: Steps 1-5 [PDF]