Social Determinants of Health: Screening & Action Steps

Healthcare today is shifting from just treating symptoms to addressing the full picture of what affects a person's well-being. That includes the places people live, the jobs they have (or don’t have), the food they can access, and how safe they feel at home. These factors, called Social Determinants of Health (SDOH), play a big role in our overall health outcomes.

But here’s the thing—simply asking patients about their social stressors isn’t enough. Screening without providing help can leave both patients and clinicians feeling stuck or frustrated. To truly improve lives, healthcare providers must not only screen for SDOH but also act on that information. In other words, asking the right questions is the first step. The next step is putting answers into action—through tailored care plans and by connecting patients with local resources.

This article will walk you through how to use proven screening tools like PRAPARE® and the CMS-HRSN tool, how to include findings in care plans, how to keep a reliable list of community resources, and how to make screening a launchpad for change instead of a dead end.

Let’s dive in.

Understanding the Value of SDOH Screening

Before jumping into the "how," let’s talk about the "why." At least 80% of a person’s health is affected by social and environmental factors, like access to food or safe housing. That’s huge. If healthcare only focuses on prescriptions and lab results, then it’s missing the bigger picture.

By identifying social needs early, healthcare professionals can:

• Personalize care plans that reflect real-life circumstances.
• Prevent emergencies by solving problems upstream.
• Strengthen trust between patients and providers.

According to the Agency for Healthcare Research and Quality (AHRQ), integrating SDOH into practice improvement helps health systems advance equity and patient-centered care.

Validated Screening Tools: PRAPARE® and CMS-HRSN

Several screening tools are designed to help clinics identify SDOH in a standardized, effective way. Two of the most trusted tools are PRAPARE® and the CMS-HRSN screening tool. Let’s take a closer look.

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

The PRAPARE® tool is widely used in community health centers and other clinical settings. It’s evidence-based, well-tested, and comes with an implementation toolkit.

Key Features:

• Covers several domains including housing, food insecurity, transportation, employment, stress, and more.
• Collects optional demographic data like race, ethnicity, and immigration status—not to link to health risks but to highlight systemic disparities.
• Integrates with electronic health records (EHRs) such as Epic and eClinicalWorks through pre-built templates.
• Offers a blend of core and optional questions, allowing flexibility.

Clinics can use PRAPARE® to collect detailed information that paints a fuller picture of the patient’s life and challenges.

CMS Accountable Health Communities Health-Related Social Needs (CMS-HRSN) Tool

Developed by the Centers for Medicare & Medicaid Services, the CMS-HRSN tool—also called the AHC HRSN tool—is compact and easy to use in fast-paced settings.

Key Features:

• 10-item screener that focuses on five core domains: housing instability, food insecurity, transportation, utility needs, and interpersonal safety.
• Designed for clinical workflows and compatible with existing patient intake systems.
• Ideal for those looking to start with a focused approach and then expand.

The CMS tool makes it easy for clinics to get started with SDOH screening without overwhelming staff or patients.

Best Practices for Implementation

Both the American Academy of Family Physicians (AAFP) and Michigan SHIELD recommend embedding SDOH screening into routine processes:

• During patient registration
• While taking social history
• In triage or rooming conversations

For speedy screening, the AAFP’s The EveryONE Project includes both short and long forms. You can even start small—try just using the Hunger Vital Sign (2 questions)—and add more domains over time.

Embedding SDOH Into the Care Plan

Once you've completed a screening, what you do next determines how successful your program will be. Capturing SDOH data is only valuable when it leads to targeted actions.

1. EHR Integration

It’s critical to log screening results into your EHR system using trusted coding systems like LOINC and SNOMED. According to OHSU’s practical guide, structured EHR fields allow for automation, including:

• Triggering referral prompts
• Automating social service alerts
• Analyzing population health trends

2. Direct Link to Interventions

Screening results should immediately lead to care plan changes. For example:

• Positive for housing insecurity → Refer to housing assistance program
• Trouble affording food → Connect with nearby food bank

A tool is only as useful as the follow-through it enables.

3. Setting Goals Within the Plan

The HEEC seven-step framework recommends that plans include clear, patient-centered goals. Examples:

• "Patient to have stable housing by December."
• "Connect with SNAP benefits within two weeks."

Specific goals help both provider and patient stay on track and measure progress.

Maintaining a Dynamic Resource Directory

So, what good is a referral if you’re sending patients to old or incorrect information? That’s where a dynamic resource directory comes in.

Building and Maintaining a Community Resource Directory

According to Health Leads, an effective directory provides up-to-date resource information and enables successful follow-up.

How to sustain a quality directory:

• Work with local government, faith groups, and charities to list services
• Assign specific staff to verify resource data quarterly
• Use platforms that allow real-time updates and patient access via portals

The more detailed and active your directory is, the more trust it builds between you and your patients.

Turning Screening Into Real Action: The 7-Step Process

Screening impacts health only if followed by strong infrastructure and commitments. The HEEC model outlines a 7-step process for successful SDOH implementation:

1. Build a Multidisciplinary Leadership Team

Include doctors, nurses, social workers, community members, and even patients. Diverse experiences lead to better pathways.

2. Map Local Resources

Identify available resources in the target community. Consider needs of special populations such as veterans, non-English speakers, or seniors.

3. Select or Build the Right Screening Tool

Choose PRAPARE®, CMS-HRSN, or tailor your own tool using trusted items like the Hunger Vital Sign for food insecurity.

4. Define Clear Patient Workflows

Decide when in the visit screening will happen. Then map the patient journey—what happens next after a positive result?

5. Design Custom EHR Templates

This saves time on documentation and ensures the information is where it needs to be for clinical actions.

6. Train All Staff

Train frontline staff in empathetic questioning. Teach clinical teams where and how to document, refer, and follow up.

7. Monitor, Evaluate, and Adapt

Don’t stop at setup. Measure what’s working—screening rates, referrals completed, patient satisfaction—and refine accordingly.

Step	Action	Benefit
1	Build a leadership team	Shared vision and responsibility
2	Map resources	Accurate, community-centered help
3	Choose the best tool	Efficient and focused screening
4	Define workflows	Streamlined patient experience
5	Integrate with EHR	Automation and easy access
6	Staff training	Consistency and compassion
7	Evaluate impact	Continuous improvement

Key Considerations

When planning your SDOH efforts, remember these extra tips:

• Always respect patient privacy and offer an opt-out. People should never feel forced to share.
• Focus on local priorities. In rural areas, transportation might be a greater challenge than utilities or food.
• Address sensitive topics like domestic violence with care and provide appropriate legal or medical referrals.

Conclusion

Screening for Social Determinants of Health is essential for holistic patient care, but actionable steps must follow to avoid frustration. Tools like PRAPARE® and CMS-HRSN offer great starting points, but they’re only half