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Community Partnerships & SDoH Referral Toolbox
Templates for SDoH screening, warm referrals, partnership agreements and tracking between healthcare teams and community services.
Community Partnerships & SDoH Referral Toolbox
Practical templates and workflows to help care teams screen for social needs, arrange warm referrals, document community partnerships, and close follow-up loops during care transitions.
Why this matters
Social determinants of health (housing instability, food insecurity, transportation, utility needs, etc.) commonly affect patients' ability to follow care plans and transition safely between settings. During discharge and care transitions, uncoordinated referrals or vague partnership agreements often mean needs go unmet. This toolbox gives teams straightforward artifacts they can adapt so referrals are more likely to connect patients to the right help.
What you'll understand and be able to do
Using this resource you can:
- Use screening templates that translate social-risk conversations into actionable referral decisions.
- Create warm-referral workflows and referral forms that capture consent, next steps, urgency, and contact information.
- Draft simple partnership agreements and memorandum-of-understanding (MOU) outlines that clarify roles, expected turnaround, and feedback loops with community-based organizations (CBOs).
- Set up basic tracking fields so care teams can record referral status and follow-up outcomes for care transitions and audits.
Who benefits
This toolbox is useful for hospital discharge teams, primary care and community clinics, home health and post-acute providers, behavioral health programs, social work teams, care coordinators, and community organizations who partner to support patients. It is designed for teams that need practical, low-friction documents they can adapt to local processes and privacy requirements.
Practical examples
- A primary-care clinic uses the screening checklist during annual visits and triggers a warm referral to a local food pantry when the patient reports food insecurity.
- A discharge planner attaches a referral form to a home-health order that includes consent, urgency level, and a requested callback time from the CBO.
- A safety-net hospital negotiates a short MOU with regional transportation services that specifies referral turnaround and feedback expectations for patients discharged to outpatient follow-up.
How to use the toolbox on this platform
The items in this toolbox are intended as starting points. Download and adapt the templates to match your local workflows, privacy policies, and legal guidance. Where your site supports interactive forms, these templates can be rendered as fillable forms and, if enabled, saved as structured JSON so referral and screening data can be tracked and audited over time. Teams may also copy or adapt documents to create site-specific toolkits that evolve with local partnerships.
Get started: Download the screening checklist, referral form, and partnership agreement templates — then tailor them to your workflows and consent practices. Use them as the basis for team huddles, transition audits, and local partner conversations.
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