A Comprehensive List of Tools for Screening for SDOH

Written by Activate Care Staff

What are the available multi-domain screening tools to identify social risk? What social risk domains do they identify?

Based on research published in the Journal of the American Medical Association, many multi-domain social risk screening tools have been developed, but they vary widely in their assessment of social risk.

These are ten of the most widely used social risk screening tools.

 


 

Hunger Vital Sign Tool

In 2010, two physicians on the Children’s HealthWatch team developed the Hunger Vital Sign, which is a validated 2-question screening tool that is widely used to identify households at risk of food insecurity.

Households are screened as being at risk for food insecurity if they answer that either or both of the following two statements is ‘often true’ or ‘sometimes true’ (vs. ‘never true’):

  • “ Within the past 12 months we worried whether our food would run out before we got money to buy more.”
  • “ Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”

 → Learn more about the Hunger Vital Sign from Children's HealthWatch.

 


 

PRAPARE Screening Tool

PRAPARE stands for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. The PRAPARE Screening Tool consists of a set of national core measures as well as a set of optional measures for community priorities.

First developed by the National Association for Community Health Centers, PRAPARE is part of a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health.

PRAPARE Electronic Health Record templates exist for eClinicalWorks, Cerner, Epic, athenaPractice (formerly GE Centricity), NextGen and more and are freely available to the public.

 → Learn more about the PRAPARE Screening Tool from NACHC.

 


 

USDA Household Food Security Tool

The Household Food Security Tool is a survey created by the United States Department of Agriculture that examines the extent and severity of food insecurity and hunger in a household.

A household is classified into one of the food security status-level categories on the basis of its score on the food security scale, while the household's scale score is determined by its overall pattern of response to the set of indicator questions.

Households with very low scale scores are those that report no, or very limited, food insecurity or hunger experiences. These households are classified as food secure. At the other extreme, households with very high scale scores are those that have reported a large number of the conditions and are classified as food insecure with hunger (severe) i.e., with hunger at the most severe level measured in the U.S.

 → Learn more about the Household Food Security Tool from the USDA.

 


 

Health Leads Screening Toolkit

The Health Leads Screening Toolkit is a comprehensive resource for best practices for screening for social needs, plus a sample screening tool, and a screener questions library.

The sample tool screens for the most common unmet social needs: food insecurity, housing instability, utility needs, financial resource strain, transportation, exposure to violence, and socio-demographic information. Some optional social need domains are childcare, education, employment, health behaviors, social isolation & supports, and behavioral/mental health. 

The Toolkit was last updated in 2018 with best practices from authorities like the Institute of Medicine, Centers for Medicare and Medicaid Services and the Centers for Disease Control & Prevention.

 → Learn more about the Screening Toolkit from Health Leads.

 → Read Activate Care's interview with a co-developer of the Health Leads Toolkit.

 


 

WE CARE Screening Tool

WE CARE stands for Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education. It is a social determinants of health screening and referral intervention. 

The WE CARE Survey instrument is designed to: (1) identify unmet social needs (e.g., childcare, employment, and housing) by self-report (e.g., "Are you employed?"), and (2) using a family-centered approach, determine whether parents would like assistance with any of their unmet needs (e.g., "If no, do you want help?").

The "would you like help?" question avoids the common screening pitfall of presuming that those who have a need want assistance addressing it.

 → Learn more about the WE CARE Screening Tool from Boston Medical Center.

 


 

Children's HealthWatch Survey

The Children's HealthWatch Survey measures the nutrition, health and development of young children and the health and economic well-being of their families.

It has been administered since 1998. During the survey, interviewers collect information about demographics, child health and development, caregiver health, housing, household food security, federal assistance program utilization and access, employment, income, financial literacy, oral health care, utilities, child care, Adverse Childhood Experiences (ACEs) and Experiences of Discrimination.

Since 2020, the survey has been administered telephonically and changed to a modular format to allow interviewers to cover more topics without overburdening caregiver participants.

 → Learn more about the Survey Tool from Children's HealthWatch.

 


 

Homelessness Screening Clinical Reminder

The Homelessness Screening Clinical Reminder assesses veterans’ current experience of housing instability as well as veterans’ imminent risk of homelessness.

The National Center on Homelessness Among Veterans developed the Homelessness Screening Clinical Reminder for use in patients’ electronic medical records to conduct a universal screen for housing instability and risk.

Administered by the Veterans Health Administration, the objective of this national screening instrument is to enhance the rapid identification of veterans and their families who have very recently become homeless or are at imminent risk of homelessness and ensure that they are referred for the appropriate assistance.

 → Learn more about the Homelessness Screening Clinical Reminder from the Veterans Health Administration.

 


 

Accountable Health Communities Screening Tool

The Accountable Health Communities Screening Tool assesses health-related social needs across five core domains (living situation, food, transportation, utilities, and safety) and eight supplemental domains (financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities).

The Accountable Health Communities Screening Tool is appropriate for use in a wide range of clinical settings, including primary care practices, emergency departments (EDs), labor and delivery units, inpatient psychiatric units, behavioral health clinics, and other places where people access clinical care.

The tool is available in three versions:

  1. A standard, self-administered version.
  2. A proxy version in which questions are adapted to enable someone to answer on behalf of the patient.
  3. A multi-use version that includes language for a proxy as well as for patients answering for themselves.

 → Learn more about the Accountable Health Communities Screening Tool from the Centers for Medicare and Medicaid Services.

 → Read Activate Care's popular overview of the Accountable Health Communities Screening Tool.

 


 

VI-SPDAT

VI-SPDAT stands for Vulnerability Index - Service Prioritization Decision Assistance Tool. It is used for triaging and assessing the needs of homeless populations.

Created by OrgCode and Community Solutions, the VI-SPDAT helps identify who should be recommended for each housing and support intervention, moving the discussion from simply who is eligible for a service intervention to who is eligible and in greatest need of that intervention.

While the SPDAT is an assessment tool, the VI-SPDAT is a survey that anyone could complete, to help prioritize clients for assistance.

 → Learn more about the VI-SPDAT from OrgCode here.

 


 

Pathways Community Hub Model

The Pathways Community Hub Model is a collection of processes, systems, and resources for community-based care coordination.

The Hub Model is designed to identify and address health, social, and behavioral health risk factors at the individual level and the community-population level. Screening in the Hub Model happens with checklists that include “trigger questions” for which a “yes” answer indicates a specific risk factor and that an interventional Pathway should be assigned.

The checklist is critical for gathering information, since many clients will not always volunteer to share concerns about domestic violence, mental health issues, or loss of health insurance coverage unless specifically asked.

 → Learn more about the Pathways Community Hub Model from PCHI here.