SDoH Screening & Referral Toolbox

Practical approaches, workflows, and documentation guidance that help clinicians identify social determinants of health (SDoH), make reliable referrals, and follow up so needs are met—not just recorded.

What this toolbox helps you do

This toolbox teaches teams how to select and adapt validated screening questions, embed screening into clinical workflows, create simple referral pathways (including warm handoffs and closed‑loop confirmation), and measure whether social needs are resolved. It focuses on pragmatic steps you can adopt in an emergency department, primary care clinic, home‑based care program, or care‑management workflow under value‑based contracts.

Why it matters

Screening without reliable referral and follow‑up leaves patients and clinicians frustrated and worsens outcomes. When screening is paired with clear referral roles, community partnerships, documentation standards, and tracking, care teams can reduce missed needs, improve care coordination, and make social care a measurable part of population health strategies.

Who benefits

Clinical teams (physicians, nurses, social workers), care managers, community health workers, clinic managers, population health leaders, and quality improvement teams will find actionable guidance here. Examples: a rural clinic building a referral directory; a hospital ED implementing a brief screen and warm‑handoff to a community navigator; a care‑management team integrating SDoH into risk stratification and outreach plans.

Core elements you'll understand and practice

- Choosing brief validated screeners and when to use expanded assessments; how to ask about housing, food, transportation, utilities, caregiving, and safety with respect and consent.
- Designing referral workflows: referral criteria, who makes the referral, warm handoffs, community partner intake, and closed‑loop confirmation.
- Documentation and measurement: consistent categorizations, basic tracking fields, handoff notes, and simple outcome indicators to include in population health reporting.
- Practical safeguards: consent, privacy, capacity checks, triage when resources are limited, and escalation processes for urgent needs.

How to use this resource in your organization

Start by mapping your current intake and referral routes, then pilot a brief validated screener in a single unit (for example, one clinic or ED shift) with clear referral contacts and a follow‑up checklist. Use short PDSA cycles to refine scripts, responsibility, and measurement. Consider converting stable templates into interactive forms or checklists to save responses and build a local registry—then iterate with community partners to improve referral success rates.