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Tools to Assess and Measure Social Determinants of Health

A first step towards addressing social determinants of health (SDOH) in any community is learning about the lived experience of residents. Understanding the social factors that impact your community and screening for SDOH can help programs determine the best strategies for addressing them.

Community Measures and Mapping Tools to Assess SDOH

There are an increasing number of resources that can help people understand how SDOH affects the health of a community. Many of these resources include measures, indices, and mapping tools to assess social conditions in a given population or location. Several of these tools are described below:

  • Based on a measure created by the Health Resources & Services Administration (HRSA), the Area Deprivation Index (ADI) accounts for income, education, employment, and housing quality at the neighborhood level. The ADI was adapted by the research team at the University of Wisconsin-Madison and allows users to rank neighborhoods by socioeconomic disadvantage at the geographic (state or national) level.
  • The National Equity Atlas provides data on demographics, racial inclusion, and the economic benefits of equity at the city, state, and national level. The tool was designed to help create a new, resilient, and equitable economy.
  • Developed by Opportunity Nation and Child Trends, the Opportunity Index uniquely combines indicators and the national, state, and county levels to show opportunities for improvement. The indicators are housed in four domains: economy, education, health, and community. The index employs a unique formula to provide users with a big-picture view and localized perspective on the conditions influencing their neighborhood.
  • The Community Need Index (CNI) provides information on community socioeconomic status at the ZIP code level. The 5-point index is based on the average of five different socioeconomic barrier scores: a score of 1 indicates little need while 5 indicates a ZIP code with high need.
  • The 2019 Healthiest Community rankings provide a breakdown of the top 100 rural, high-performing communities. Identified by experts through a collaboration between U.S. News & World Report and the Aetna Foundation, cities are assessed based on 10 categories: population health, equity, education, economy, housing, food & nutrition, environment, public safety, community vitality, and infrastructure. The platform includes an interactive Data Explorer for users to further explore data and trends.
  • County Health Rankings & Roadmaps is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute that measures important health factors in communities around the U.S. in an effort to drive change towards improving health. The program provides snapshots of community health as well as a community ranking system.

Assessing Individual Social Risk Factors in Healthcare Settings

In addition to community-level tools to assess SDOH, healthcare settings have an increasing interest in measuring individual social risk factors to help address SDOH. Social risk factors are social and relational factors that have been found to influence individual health outcomes. The National Academies of Sciences separates social risk factors into 5 domains:

  • Socioeconomic position
  • Race, ethnicity, and cultural context
  • Gender
  • Social relationships
  • Residential and community context

In healthcare settings, specialized screening tools can allow healthcare providers to assess and monitor social needs and risk factors of patients. Several screening tools available for download and printing are described below:

  • The Health-Related Social Needs (HRSN) Screening Tool is a standard screening tool developed by the Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation (CMMI) to determine if systematically screening for health-related social needs has an effect on total healthcare costs and health outcomes. The HRSN Screening tool includes 10 items categorized into 5 domains: housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety.
  • PRAPARE Implementation and Action Toolkit compiles resources, best practices, and lessons learned from health centers focused on how to implement a SDOH data collection initiative. The toolkit is accompanied by an assessment tool. The tool was developed based on a review of existing SDOH that consists of a set of national core measures to help standardize data collection.
  • The HealthBegins screening tool was developed to spark discussions among healthcare providers about incorporating SDOH data to better inform patient care. The tool consists of questions on topics such as education, employment, social support, immigration, and violence.

Increasingly, electronic tools are being used to screen for SDOH in healthcare settings. These tools can record findings directly in a patient's electronic health record. For example, healthcare providers can now use select ICD-10-CM codes to identify patients with potential health hazards that may be related to socioeconomic and psychosocial circumstances.

Health Impact Assessments

Health Impact Assessments (HIAs) are a decision-support tool designed to help community stakeholders investigate how a proposed program, project, policy, or plan may impact the health and well-being of a population. HIAs are flexible, using available resources and variations of qualitative and quantitative data sources and methods. They are also based on stakeholder input, providing the opportunity to engage with community members, planners, and non-traditional health partners. Major steps in conducting a HIA include:

  • Screening
  • Scoping
  • Assessment
  • Recommendations
  • Reporting
  • Monitoring and evaluation

See Health in All Policies for more information about how HIAs can be used to guide Health in All Policies initiatives.

Resources to Learn More

The EveryONE Project Toolkit
Website
Provides information to help healthcare providers better understand and address SDOH in their patient community. Includes resources to embed equity into healthcare settings, as well as tools to be able to assess and screen for SDOH.
Organization(s): American Academy of Family Physicians

Health Care Innovations for Rural Populations
Website
Includes case studies and tools related to improving healthcare quality and access for rural populations. Includes articles addressing topics such as telehealth, remote monitoring, rural behavioral healthcare, mobile clinics, and outreach services.
Organization(s): Agency for Healthcare Research and Quality

Health Impact Assessment
Website
Describes NACCHO's Health Impact Assessment Project which aims to provide support for local health departments who want to learn about and implement HIAs.
Organization(s): National Association of County and City Health Officials (NACCHO)

Health Impact Assessment: A Tool for Promoting Health in All Policies
Document
Describes the HIA process and examples of its use. Explains stakeholder involvement and the impact HIAs can have on community health and well-being.
Organization(s): Robert Wood Johnson Foundation
Date: 5/2011

How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care
Document
Provides examples of processes used by organization to develop SDOH screening tools for ambulatory care.
Author(s): LaForge, K., Gold, R., Cottrell, E., et al.
Citation: Journal of Ambulatory Care Management, 41(1), 2-14
Date: 1/2018

Neighborhood Navigator
Website
Connects users to community resources and programs in their neighborhood. Highlights local services related to SDOH such as food, housing, transportation, employment, legal aid, and more. The AAFP provides additional tools and resources to help address SDOH among patients.
Organization(s): American Academy of Family Physicians

Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations
Document
Summarizes how organizations participating in Robert Wood Johnson's Transforming Complex Care (TCC) Initiative are working to identify and address SDOH for populations with complex needs. Includes considerations for selecting, adapting, and adopting assessment tools; collecting and integrating SDOH information; and creating workflows to track patients' needs.
Organization(s): Center for Health Care Strategies, Inc.
Date: 10/2017