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Quick Finds: Social Determinants of Health

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Introduction. Use this page to quickly find all resources from the Clearinghouse database on special and vulnerable populations.

Background. Social Determinants of Health are the social conditions that influence individual and community health. Those determinants include housing, poverty, nutrition, education and family stability.

You can learn what the Social Determinants of Health Academy is doing in this area.

Highlighted Resource. HRSA’s Bureau of Primary Health Care has developed the following resource: Social Determinants of Health (SDOH): Targeted Training and Technical Assistance (T/TA) Resources for Health Care for the Homeless Centers (HCH) Considering Adopting SDOH Screening

Submit Resources. If you have a resource that you believe should be contained in the Clearinghouse, please complete the Submit a Resource form.

Results for: Topic Area = Social Determinants of Health

Displaying records 1 through 50 of 449.

Reframing Trauma Informed Care as a Systems Approach (2022). Resource Type: Podcast. Description: The National Nurse-Led Care Consortium (NNCC) invites you to listen to the final episode in their Fall podcast series where we speak to community health professionals Kathleen Metzker and Sara Reid about centering trauma literacy in the health center medical home and how health systems can cultivate trauma-aware practices as part of their delivery of care. Metzker and Reid are interviewed by Jillian Bird, NNCC’s Director of Training and Technical Assistance. More Details...

Community Inclusion and Cultural Humility in Diabetes Prevention (2022). Resource Type: Archived Webinar. Description: The National Nurse-Led Care Consortium (NNCC) hosted a webinar focused on cultural humility and strategies for community inclusion in diabetes care. Subject matter expert Tiana Matthews-Martinez RD shared best implementations practices and real accounts of developing patient-centered diabetes prevention programs, treatments, and educational interventions tailored toward residents of public housing. Participants learned how to apply cultural humility to diabetes care while engaging community members in culturally and linguistically responsive healthcare practices to address racial and ethnic health disparities. More Details...

Recommendations for Mental Health and Underserved Latino Populations: Special Focus on Migrant Seasonal Agricultural Workers (2022). Resource Type: Publication. Description: Mental health is crucial to an individual’s overall health and well-being. Research has shown that mental health diagnoses, such as depression, are linked to an increase in the risk of many types of physical health problems, particularly chronic conditions such as diabetes, heart disease, and stroke. Improving access to mental health services is a complex and multifaceted endeavor. The recommendations in this publication are offered to overcome barriers expressed by the Hispanic/Latino and MSAW population. More Details...

Culturally Appropriate Healthy Eating Educational Tool for Asian Americans: Filipino and Hmong Editions Webinar (2022). Resource Type: Archived Webinar. Description: AAPCHO and MHP Salud presented four culturally relevant My Healthy Plate brochures that include the cultural traditions and dietary preferences of Filipino/a/x and Hmong Migrant Seasonal Agricultural Worker Program (MSAW) communities as critical tools in preventing diabetes. In this webinar, speakers from Mabuhay Health Center and Minnesota Community Care shared the importance of culturally relevant My Healthy Plate educational resources, a national survey and health center collaboration efforts, and promising practices. MHP Salud introduced their series of culturally appropriate My Healthy Plate educational resources and how they increase organizational capacity at Health Centers through community health worker (CHW)-led programs. More Details...

NTTAP Webinar Series - December 12, 2022: HIV Prevention: Combating PrEP Implementation Challenges (2022). Resource Type: Archived Webinar. Description: Expert faculty present case-based scenarios illustrating common challenges to integrating HIV PrEP in primary care. As part of improving clinical workforce development, this session will delve into a variety of specific PrEP implementation challenges. Participants will leave with strategies to overcome these obstacles to establish or strengthen their PrEP program. More Details...

Improving Care Coordination and Health Outcomes for Diabetic Patients through Medical and Dental Integration: Promising Practice (2022). Resource Type: Publication. Description: CommUnityCare in Texas shares how their organization implemented medical and dental integration through NNOHA Integration of Diabetes and Oral Health Learning Collaborative to help improve the health outcomes of patients with diabetes. More Details...

Using MLP to Address the Legal Needs among Racial & Ethnic Minorities Living with HIV (2022). Resource Type: Archived Webinar. Description: In this webinar, the presenters discussed recent HIV epidemiological data and the current landscape of healthcare and social needs for this patient population. Presenters also shared best practices and examples for health center and MLP staff to improve screening and implementation of legal interventions that are designed to help reduce and prevent racial disparities and health inequities for people living with HIV. More Details...

Diabetes Continuum of Care: Understanding Social Determinants of Health and Structural Barriers Affecting Diabetes Care.: Part 1 of the 2022 Diabetes Special and Vulnerable Populations Task Force National Learning Series (2022). Resource Type: Archived Webinar. Description: This session is part 1 of 4 in the 2022 Diabetes Special and Vulnerable Population Task Force National Learning Series. This session was entitled \"Understanding Social Determinants of Health and Structural Barriers Affecting Diabetes Care\" More Details...

Recommendations for Mental Health and Underserved Latino Populations: Special Focus on Migrant Seasonal Agricultural Workers (2022). Resource Type: Publication. Description: Mental health is crucial to an individual’s overall health and well-being. Research has shown that mental health diagnoses, such as depression, are linked to an increase in the risk of many types of physical health problems, particularly chronic conditions such as diabetes, heart disease, and stroke. Improving access to mental health services is a complex and multifaceted endeavor. The recommendations in this publication are offered to overcome barriers expressed by the Hispanic/Latino and MSAW population. More Details...

Advancing MLP in Health Centers Serving Special Populations: Case Studies Covered through an MLP Peer Learning Collaborative (2022). Resource Type: Publication. Description: In 2021, health center MLP practitioners gathered for a four-part learning collaborative designed to help them develop and improve their partnership models to better serve the needs of special populations. This factsheet summarizes the learning goals, case studies, and some of the salient points shared throughout the four sessions. More Details...

Equitable Diabetes Prevention: Keys to Success from a Pacific Islander Community (2022). Resource Type: Podcast. Description: The National Nurse-Led Care Consortium (NNCC) and the Association of Asian Pacific Community Health Organizations (AAPCHO) invite you to listen to the second episode in NNCC’s Fall podcast series where we discuss equitable diabetes prevention services for special and vulnerable populations, specifically Pacific Islanders. NNCC\'s Jillian Bird speaks to Jen Lee from AAPCHO and Cecilia Sigrah from Kosrae Community Health Center in the Federated States of Micronesia about the rollout of their Pacific Islander Diabetes Prevention Program (PI-DPP) and the outcomes of providing a tailored prevention program. More Details...

Partnership for the Future: Health Centers and Maternal Child Health Home Visiting Opportunities (2022). Resource Type: Publication. Description: The National Nurse-Led Care Consortium (NNCC) has developed a publication on Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funded home visiting programs working in partnership with health centers. The publication outlines key steps and resources for integrating MIECHV programs and health centers and provides examples of successful collaborations. More Details...

“No Wrong Door” for Veterans: Veteran Cultural Competency Training for MLP Teams (2022). Resource Type: Archived Webinar. Description: Partnerships between health centers, the VA, and civil legal services providers help to ensure that Veterans can access health care through “no wrong door.” To improve the capacity of these partnerships to meet the holistic needs of Veterans, medical-legal partnership staff of all backgrounds and skill sets were invited to this free training event on Veterans cultural competency. Through this webinar, the audience learned about current best practices for serving Veterans across settings and increase their understanding of how to use the medical-legal partnership approach to address the health-harming legal needs of Veterans and their families. Attendees heard from Emily Edwards, PhD (DBT for Justice-Involved Veterans, VISN 2 MIRECC, TASC, James J. Peters VA Medical Center); Lara Eilhardt, JD (Office of General Counsel), and Madolyn Gingell, LCSW (Legal Services for Veterans Program). More Details...

What Health Centers Can Do to Advance the Vital Role for Community Health Workers and Peers in SDOH Screening for Positive Health Outcomes (2022). Resource Type: Archived Webinar. Description: MHP Salud, CSH, and NHCHC collaborated to present a national webinar that highlighted the value of the Community Health Workers (CHWs)/Peer Specialists in health centers through SDOH community connections. Presented in a coffee chat format, this webinar was interactive and featured various resources that focus on the strategies identified through the voice of lived expertise and education partners. More Details...

Kit de herramientas de redes sociales y actividades de alcance sobre la influenza para trabajadores agrícolas (2022). Resource Type: Toolkit. Description: El kit de herramientas de alcance y redes sociales sobre la gripe para trabajadores agrícolas proporciona información y herramientas tangibles para apoyar a los centros de salud y otras organizaciones comunitarias en el uso de plataformas de redes sociales para compartir mensajes efectivos sobre la gripe a los trabajadores agrícolas y sus familias. More Details...

How Compassion and Relationships Reduce Chronic Stress (2022). Resource Type: Podcast. Description: The National Nurse-Led Care Consortium (NNCC) invites you to listen to the first episode of their Fall podcast series. Join them in reflecting on how compassion and relationships can mitigate the negative health impacts of chronic stressors. More Details...

Promising Training Practices to Meet the Needs of Providers & Patients (2022). Resource Type: Archived Webinar. Description: This webinar aimed to help health centers who are developing or have an established MLP increase their capacity to build a stable, committed, and skilled workforce that can meet the health-harming legal needs of their patients and communities. More Details...

Developing Screening, Referral, & Service Delivery Workflows for MLPs (2022). Resource Type: Archived Webinar. Description: In this first webinar of the MLP in health centers toolkit series, we revisited our foundation and learned about the evolving health and social needs of health center patients. This time, we took a deeper dive into how PRAPARE is being used to screen for social needs and risk stratification as well as how to build a screenings/referrals/service delivery workflow specific to MLPs. More Details...

Diabetes Across the Lifespan: Healthy Eating Considerations for Latino Populations (2022). Resource Type: Publication. Description: Vulnerable populations are at a higher risk for chronic illnesses such as diabetes due to their lack of access to healthcare and healthy food options. Most common foods in the Hispanic/Latino culture are high in sugar and carbohydrates, which lends itself to the high rates of diabetes within this community. Community Health Workers deliver culturally inclusive health education resources that help Latinos, and other high-risk populations choose the correct meals and portions to manage diabetes and stay in better physical shape. More Details...

Health Center & Justice System Collaboration to Improve Mental Health (2022). Resource Type: Archived Webinar. Description: Recognizing the potential link between HCs and the justice system, Shannon Mace and James Teufel worked with a host of key informants to write the 2022 issue brief Connecting Community Health Centers & Courts to Improve Behavioral Health of People & Communities, which explores the further integration of and partnership between health centers, certified community behavioral health clinics, and courts to improve the continuum of care. Attendees heard from the authors and Patti Tobias (National Center for State Courts) on October 11, 2022 as they discussed their findings and the ways in which Health Centers and Justice Systems can collaborate to improve the mental health of patients and justice-involved individuals. More Details...

Health Center & Justice System Collaboration to Improve Mental Health (2022). Resource Type: Archived Webinar. Description: Recognizing the potential link between HCs and the justice system, Shannon Mace and James Teufel worked with a host of key informants to write the 2022 issue brief Connecting Community Health Centers & Courts to Improve Behavioral Health of People & Communities, which explores the further integration of and partnership between health centers, certified community behavioral health clinics, and courts to improve the continuum of care. Attendees heard from the authors and Patti Tobias (National Center for State Courts) on October 11, 2022 as they discussed their findings and the ways in which Health Centers and Justice Systems can collaborate to improve the mental health of patients and justice-involved individuals. More Details...

Social Determinants of Health (SDOH): Targeted Training and Technical Assistance (T/TA) Resources for Health Care for the Homeless Centers (HCH) Considering Adopting SDOH Screening (2022). Resource Type: Publication. Description: The Bureau of Primary Health Care (BPHC) invests in T/TA to support health center clinical, operational, and fiscal excellence. To increase awareness and utilization of the T/TA resources developed by BPHC-funded T/TA providers, BPHC staff have created targeted (T/TA) resources, which include curated resources in high-need areas. More Details...

Understanding the Current Social Needs of Health Center Patients (2022). Resource Type: Archived Webinar. Description: NCMLP kicked off its annual Health Center Medical-Legal Partnership (MLP) Webinar Series on September 20, 2022. This webinar series, based on the Health Center Toolkit, is designed to provide T/TA for the health center field on the core components of MLP and the advanced application of medical-legal partnership planning, implementation and growth. After almost two and a half years of adjusting services and operations to meet the evolving needs of low-income populations during the ongoing public health emergency, panelists and attendees strengthened their foundational knowledge and understanding of the data on current and emerging social needs for health center patient populations. Attendees heard from the following subject matter experts: • Brad Corallo, KFF • Rosy Weir, AAPCHO • Albert Ayson, Jr., AAPCHO More Details...

Increasing Capacity to Address Health, Justice, & Equity Through Partnerships (2022). Resource Type: Publication. Description: Given their disproportionate share of patients or clients who are survivors, this guide provides select tools and resources for the following key partners and allies: HEALTH CENTERS | To promote collaboration with DV programs and civil legal aid organizations, and help establish medical-legal partnerships (MLPs) DV PROGRAMS | To promote collaboration with HCs/civil legal programs CIVIL LEGAL AID ORGANIZATIONS | To promote collaboration with HCs/DV programs/establish MLPs ESTABLISHED MLPS | To promote DV/HT/E as issues they can address, intersectional with other I-HELP areas of work More Details...

The Health of Asian American, Native Hawaiian, and Pacific Islander Patients Served at Health Centers: An Analysis of the 2020 Uniform Data System (2022). Resource Type: Publication. Description: This report examines current patient demographics and utilization of health services at health centers serving Asian Americans (AAs) and Native Hawaiians and Pacific Islanders (NH/PIs), and highlights the differences between these centers and the national average of all health centers in the United States. More Details...

Two-Tiered Screening for Patient Socila Needs in a Safety-Net Setting: Using Two Pre-Screening Questions to assess patients’ social needs at a Chicago-area FQHC (2022). Resource Type: Template. Description: Erie Family Health Centers, a Chicago-area Federally Qualified Health Center, initiated a two-part social needs screening process with patients in May 2020. A medical assistant asked a single prescreening question about interest in being connected to resources and interested patients received a follow-up call from staff to screen for needs and connect with resources. A second prescreening question was added asking patients their preferred method for receiving resources. The results of this process suggest that a two-tiered screening for social needs is feasible in the safety net setting. More Details...

Connecting Community Health Centers & Courts to Improve Behavioral Health of People & Communities (2022). Resource Type: Publication. Description: As an exploration of the intersection of health and justice, Connecting Community Health Centers & Courts to Improve Behavioral Health of People & Communities offers nine major recommendations for health centers and courts to better support the behavioral health of justice-involved people. This brief proposes ways in which these organizations can collaborate and ultimately foster the next phase of the medical-legal partnership movement: bringing the health provider into the legal context and expanding the pool of potential legal services providers. More Details...

Strengthening Social Connection in Older Adults (2022). Resource Type: Publication . Description: This guide details the impact of social isolation and feelings of loneliness on older adult health. Social isolation might be identified during SDOH screening and this oublication reviews patient resources that are appropriate for multiple levels of technology literacy. More Details...

Realizing Resilience Part 3: Two Years Later, Updates on Health Center and Social Sector Response to Address Social Drivers of Health Needs during COVID-19 (2022). Resource Type: Publication. Description: This publication summarizes key takeaways identified by health centers when detecting, prioritizing, and informing community health-related social needs that were magnified by the COVID-19 pandemic. More Details...

“Acting on Social Determinants of Health Screening Data to Address Barriers to Health” Webinar (2022). Resource Type: Archived Webinar. Description: AAPCHO, Health Outreach Partners (HOP), MHP Salud, and National Health Care for the Homeless Council (NHCHC) hosted a HRSA-sponsored webinar to explore strategies to screen special and vulnerable populations for social determinants of health (SDOH) and build effective practices to begin addressing SDOH through outreach and enabling services (ES). More Details...

Tips to Help Health Centers Address Disability & Chronic Disease Discrimination (2022). Resource Type: Publication. Description: This tip sheet provides advice as well as key resources to help staff of health centers and look-alike programs quickly improve their understanding of the important role they can play in helping to identify discrimination at its earliest stages and how to mitigate it by leveraging their own medical authority and resources within the community. More Details...

National Center for Health in Public Housing’s Smoking Cessation Protocol: A Guide to Conducting Groups (2022). Resource Type: Publication. Description: This guide provides readers with all necessary information and supplemental materials that are needed to conduct a comprehensive smoking cessation program either in a group setting, or with individual patients. More Details...

Impact of COVID-19 On Public Housing Primary Care (PHPC) Health Center Patients and Operations (2022). Resource Type: Publication. Description: This publication by NCHPH highlights findings from a survey distributed to public housing residents assessing the effects that COVID-19 has had on Public Housing Primary Care (PHPC) patients and health center operations. More Details...

How Health Centers Can Promote Benefits of Exercise to Diabetic Public Housing Residents and Promising Practices (2022). Resource Type: Publication. Description: This publication by NCHPH discusses the importance of exercise among public housing patients with diabetes, in addition to how it can benefit them. More Details...

Healthy Together: A Toolkit for Health Center Collaborations with HUD Assisted Housing and Community-Based Organizations (2022). Resource Type: Toolkit. Description: This toolkit by NCHPH and NNCC provides information and resources for health center staff to partner and collaborate more effectively with their local housing authorities and with other providers serving residents of public housing and other low-income housing. More Details...

Data Discovery: Snapshot of Social Determinants of Health in Public Housing Primary Care Communities (2022). Resource Type: Publication. Description: This brief describes the findings of an online mapping resource that shows the distribution of Social Determinants of Health (SDOH) indicators across counties with Public Housing Primary Care (PHPC) health centers. More Details...

Using SDOH Data to Screen for Social Vulnerability (2022). Resource Type: Archived Webinar. Description: NCHPH, JSI, and HITEQ hosted a webinar that discussed how health centers can access and use available SDOH data sources to determine and screen the social vulnerability of their patients and link them to appropriate care and services. More Details...

The Role of Family Caregivers in Older Adult Nutrition (2022). Resource Type: Archived Webinar. Description: This National Center for Health in Public Housing (NCHPH) and National Center for Equitable Care for Elders (NCECE) webinar shared approaches to working with caregivers to address barriers to healthy eating and provide nutrition education that meets the diverse needs of older adults. More Details...

The Impact of Health Literacy on Diabetes (2022). Resource Type: Publication. Description: This blog by NCHPH explains how health literacy can affect persons living with diabetes in addition to its benefits. More Details...

The COVID-19 Pandemic and the Health Center Workforce: Challenges and Solutions (2022). Resource Type: Archived Webinar. Description: Despite increasing demand for health care services, health centers indicate a critical shortage of staff necessary to meet that demand. Burnout, stress, depression, etc. have eroded our healthy workforce. This Facebook Live session discussed workforce challenges and how to navigate these challenges. More Details...

Social Determinants of Health (SDOH) Screening Tools 101 for Health Center Staff Serving Public Housing Residents (2022). Resource Type: Archived Webinar. Description: NCHPH convened a webinar that discussed the importance of screening for social determinants of health (SDOH) More Details...

SDOH Academy Innovations Showcase Kickoff Webinar (2022). Resource Type: Archived Webinar. Description: In this webinar, health centers were provided the opportunity to demonstrate the work that they have been doing to address Social Determinants of Health. More Details...

Implementing Screening of People with Disabilities and Functional Needs During Disasters (2022). Resource Type: Archived Webinar. Description: This learning collaborative is designed to help health centers work with people with disabilities to create customized emergency preparedness kits and plans. More Details...

COVID-19 Vaccine Resource Guide (2022). Resource Type: Publication. Description: This publication provides a compilation of COVID-19 vaccine activities conducted by NCHPH. More Details...

COVID-19 By The Numbers Infographics 2021 (2022). Resource Type: Publication. Description: NCHPH analyzed survey data reports from Public Housing Primary Care (PHPC) Health Centers fielded by the Bureau of Primary Care. These infographics by NCHPH provide the latest statistics in Public Housing Primary Care Health Centers for the year 2021. More Details...

Collection of Promising Practices on Health Center and Housing Partnerships (2022). Resource Type: Publication. Description: NCHPH has catalogued promising practices on health center and housing partnerships that were identified during T/TA activities. More Details...

Addressing COVID-19’s Impact on Health Centers’ Finance and Operations and Response Planning for Future COVID-19 Outbreaks and Other Emergencies (2022). Resource Type: Archived Webinar. Description: This learning collaborative guides participants through the challenges and solutions for addressing the financial and operational impacts of COVID-19 on health centers serving residents of public housing and other underserved communities, with an emphasis on applied response planning for future emergencies. More Details...

Addressing Barriers to Diabetes Management for Residents of Public Housing (2022). Resource Type: Archived Webinar. Description: This Facebook Live session reviewed behavioral interventions that incorporate promising practices for public housing residents to manage diabetes and its complications. More Details...

A New Normal: Learning to Live with COVID (2022). Resource Type: Archived Webinar. Description: In this Facebook live session, we discussed what a health center is doing to adapt to an endemic COVID-19 era. This session included infection control approaches, outreach, on-site and virtual visits, and strategies to improve primary health services. More Details...

Market Assessment Toolkit for Health Centers (2022). Resource Type: Publication. Description: By utilizing a Market Assessment, health centers can analyze their markets and service areas in geographic, demographic, and economic terms in order to make informed observations and guide strategic decisions. More Details...

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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.