World Health Organization. Social determinants of health. Available from: https://www.who.int/social_determinants/en/. Accessed 17 Sept 2021.
Key Health Inequalities in Canada A National Portrait. Public Health Agency of Canada; 2018.
Benzeval MBL, Campbell M, Egan M, Lorenc T, Petticrew M, Popham F. How does money influence health? York: Joseph Rowntree Foundation; 2014.
Department of Health and Social Security. Inequalities in Health: Report of a Research Working Group. London: Department of Health and Social Security; 1980.
Marmot M. The status syndrome: how your social standing affects your health and life expectancy. London: Bloomsbury; 2004.
Chung RY-N, Chung GK-K, Gordon D, Wong SY-S, Chan D, Lau MK-W, et al. Deprivation is associated with worse physical and mental health beyond income poverty: a population-based household survey among Chinese adults. Qual Life Res. 2018;27(8):2127–35.
Haushofer J, Fehr E. On the psychology of poverty. Science. 2014;344(6186):862–7.
Raphael D, Macdonald J, Colman R, Labonte R, Hayward K, Torgerson R. Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation. Health Policy. 2005;72(2):217–32.
Lustig DC, Strauser DR. Causal relationships between poverty and disability. Rehabil Couns Bull. 2007;50(4):194–202.
Willson A, Erfani A. Socioeconomic history & preventable disease: a comparative analysis of fundamental cause theory. London: Conference on Health Over the Life Course; University of Western Ontario; 2009.
Bushnik T, Tjepkema M, Martel L. Socioeconomic disparities in life and health expectancy among the household population in Canada. Health Rep. 2020;31(1):3–14.
Finkelstein M. Relationship between income and mortality in a Canadian family practice cohort. Can Fam Physician. 2018;64(4):e181–e9.
Lightman EMA, Wilson B. Poverty is making us sick: a comprehensive survey of income and health in Canada. Toronto: Wellesley Institute; 2008.
Forget EL. The town with no poverty: the health effects of a Canadian guaranteed annual income field experiment. Can Public Policy. 2011;37(3):283–305.
Kaufman A. Theory vs practice: should primary care practice take on social determinants of health now? Yes. Ann Fam Med. 2016;14(2):100–1.
Solberg LI. Theory vs practice: should primary care practice take on social determinants of health now? No. Ann Fam Med. 2016;14(2):102–3.
Runyan CN. Assessing social determinants of health in primary care: liability or opportunity? Fam Syst Health. 2018;36(4):550–2.
Paula Braveman PLGL, Francis D, Arkin E, Acker J. What can the health care sector do to advance health equity? Princeton: Robert Wood Johnson Foundation; 2019.
Williamson DL. The role of the health sector in addressing poverty. Can J Public Health. 2001;92(3):178–83.
Onie R, Lavizzo-Mourey R, Lee T, Marks J, Perla R. Integrating social needs into health care: a twenty-year case study of adaptation and diffusion. Health Aff. 2018;37(2):240–7.
Taylor LA, Tan AX, Coyle CE, Ndumele C, Rogan E, Canavan M, et al. Leveraging the social determinants of health: what works? PLoS One. 2016;11(8):e0160217.
Starfield B. Is primary care essential? Lancet. 1994;344(8930):1129–33.
Riley M, Laurie AR, Plegue MA, Richarson CR. The adolescent “expanded medical home”: school-based health centers partner with a primary care clinic to improve population health and mitigate social determinants of health. J Am Board Fam Med. 2016;29(3):339–47.
Davis TK, Montford CR, Read C. Interdisciplinary teamwork in a school-based health center. Nurs Clin North Am. 2005;40(4):699–+.
Primary health care. World Health Organization. Available from: https://www.who.int/news-room/fact-sheets/detail/primary-health-care. Accessed 17 Sept 2021.
LaForge K, Gold R, Cottrell E, Bunce AE, Proser M, Hollombe C, et al. How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview. J Ambulatory Care Manage. 2018;41(1):2–14.
Health Leads. Screening for social determinants of health among children and families living in poverty: a guide for clinicians. Available from: https://healthleadsusa.org/resources/screening-for-social-determinants-of-health-among-children-and-families-living-in-poverty-a-guide-for-clinicians/. Accessed 17 Sept 2021.
Grus I, Bunce A, Davis J, Dambrun K, Cottrell E, Gold R. Initiating and implementing social determinants of health data collection in community health centers. Popul Health Manag. 2020;02:02.
O'Gurek DT, Henke C. A practical approach to screening for social determinants of health. Fam Pract Manag. 2018;25(3):7–12.
Silverstein M, Conroy K, Sandel M. Screening for social determinants of health in pediatric primary care. Pediatr Ann. 2008;37(11):740–6.
Pescheny J, Randhawa G, Pappas Y. Patient uptake and adherence to social prescribing: a qualitative study. BJGP Open. 2018;2(3):bjgpopen18X101598.
Abbott S. Prescribing welfare benefits advice in primary care: is it a health intervention, and if so, what sort? J Public Health Med. 2002;24(4):307–12.
Jones MK, Bloch G, Pinto AD. A novel income security intervention to address poverty in a primary care setting: a retrospective chart review. BMJ Open. 2017;7(8):e014270.
Klass P, Dreyer BP, Mendelsohn AL. Reach out and read: literacy promotion in pediatric primary care. Adv Pediatr. 2009;56(1):11–27.
Vasan A, Solomon BS. Use of colocated multidisciplinary services to address family psychosocial needs at an urban pediatric primary care clinic. Clin Pediatr (Phila). 2015;54(1):25–32.
Goldfarb S. Take two aspirin and call me by my pronouns. Wall Street Journal. 2019. Available from: https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291. Accessed 17 Sept 2021.
Tudor HJ. The inverse care law. Lancet. 1971;297(7696):405–12.
Watt G. The inverse care law today. Lancet. 2002;360(9328):252–4.
Garg A, Boynton-Jarrett R, Dworkin PH. Avoiding the unintended consequences of screening for social determinants of health. JAMA. 2016;316(8):813–4.
Goldstein D, Holmes J. Health care’s blind side. Princeton: Robert Wood Johnson Foundation; 2011.
Boozary A, Laupacis A. The mirage of universality: Canada’s failure to act on social policy and health care. Can Med Assoc J. 2020;192(5):E105–E6.
De Marchis EH, Alderwick H, Gottlieb LM. Do patients want help addressing social risks? J Am Board Fam Med. 2020;33(2):170–5.
Garg A, Jack B, Zuckerman B. Addressing the social determinants of health within the patient-centered medical home: lessons from pediatrics. JAMA. 2013;309(19):2001–2.
Andermann A. Taking action on the social determinants of health in clinical practice: a framework for health professionals. Can Med Assoc J. 2016;188(17–18):E474–E83.
College of Family Physicians of Canada. ePanel report: social determinants of health. Mississauga: College of Family Physicians of Canada; 2016.
Fichtenberg CM, Alley DE, Mistry KB. Improving social needs intervention research: key questions for advancing the field. Am J Prev Med. 2019;57(6):S47–54.
Cannuscio C, Meisel ZF, Feuerstein-Simon R. Social justice is the foundation of healthcare — and medical education l Opinion. Philadelphia: Philadelphia Inquirer; 2019. Sect. Opinion.
Andermann A. Screening for social determinants of health in clinical care: moving from the margins to the mainstream. Public Health Rev. 2018;39(1):19.
Fraze TK, Brewster AL, Lewis VA, Beidler LB, Murray GF, Colla CH. Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals. JAMA Netw. 2019;2(9):e1911514.
Boch S, Keedy H, Chavez L, Dolce M, Chisolm DJ. An integrative review of social determinants of health screenings used in primary care settings. J Health Care Poor Underserved. 2020;31(2):603–22.
Carter N, Valaitis RK, Lam A, Feather J, Nicholl J, Cleghorn L. Navigation delivery models and roles of navigators in primary care: a scoping literature review. BMC Health Serv Res. 2018;18(1):96.
Pescheny JV, Pappas Y, Randhawa G. Facilitators and barriers of implementing and delivering social prescribing services: a systematic review. BMC Health Serv Res. 2018;18(1):86.
Tierney S, Wong G, Roberts N, Boylan AM, Park S, Abrams R, et al. Supporting social prescribing in primary care by linking people to local assets: a realist review. BMC Med. 2020;18(1):49.
Lucyk K, McLaren L. Taking stock of the social determinants of health: a scoping review. PLoS One. 2017;12(5):e0177306.
Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients’ social and economic needs. Am J Prev Med. 2017;53(5):719–29.
Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141–6.
Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5(1):69.
The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2015 edition/supplement. Adelaide: The Joanna Briggs Institute; 2015.
Colquhoun HL, Levac D, O'Brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014;67(12):1291–4.
Peterson J, Pearce PF, Ferguson LA, Langford CA. Understanding scoping reviews: definition, purpose, and process. J Am Assoc Nurse Pract. 2017;29(1):12–6.
Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.
Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.
Downe-Wamboldt B. Content analysis: method, applications, and issues. Health Care Women Int. 1992;13:313–21.
Lombardi BM, Zerden LS, Richman EL. Where are social workers co-located with primary care physicians? Soc Work Health Care. 2019;58(9):885–98.
Kangovi SMN, Grande D, Long JA, Asch DA. Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Aff. 2020;39(2):207–13.
Davis-Hall M. The Bromley by Bow Centre: harnessing the power of community. Br J Gen Pract. 2018;68(672):333.
Krist AH, O'Loughlin K, Woolf SH, Sabo RT, Hinesley J, Kuzel AJ, et al. Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial. Trials. 2020;21(1):517.
Zhu E, Ahluwalia JS, Laws MB. An evaluation of connect for health: a social referral program in RI. R I Med. 2020;103(5):65–9.
Perrin EC. Screening for both child behavior and social determinants of health in pediatric primary care: commentary. J Dev Behav Pediatr. 2019;40(6):470–1.
Kleinman RE, Murphy JM, Wieneke KM, Desmond MS, Schiff A, Gapinski JA. Use of a single-question screening tool to detect hunger in families attending a neighborhood health center. Ambul Pediatr. 2007;7(4):278–84.
Brcic VEC, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med. 2011.
Health Leads. Social needs screening toolkit. Boston: Health Leads; 2016.
National Association of Community Health Centers. Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE). Available from: https://www.nachc.org/research-and-data/prapare/. Accessed 17 Sept 2021.
Byhoff E, Cohen AJ, Hamati MC, Tatko J, Davis MM, Tipirneni R. Screening for social determinants of health in Michigan health centers. J Am Board Fam Med. 2017;30(4):418–27.
Bleacher H, Lyon C, Mims L, Cebuhar K, Begum A. The feasibility of screening for social determinants of health: seven lessons learned. Fam Pract Manag. 2019;26(5):13–9.
Burke G, Ramos-Callan K, Shearer C. Complex construction: a framework for building clinical-community partnerships to address social determinants of health. New York: United Hospital Fund; 2019.
Billioux A, Verlander K, Anthony S, Alley D. In: Medicine NAo, editor. Standardized screening for health-related social needs in clinical settings the accountable health communities screening tool; 2017.
Naz A, Rosenberg E, Andersson N, Labonté R, Andermann A. Health workers who ask about social determinants of health are more likely to report helping patients: mixed-methods study. Can Fam Physician. 2016;62(11):e684–e93.
New MLP legal needs screening tool available for download. Washington, DC: National Center for Medical-Legal Partnership; 2015. Available from: https://medical-legalpartnership.org/screening-tool/. Accessed 17 Sept 2021.
Maxwell M, Hibberd C, Aitchison P, Calveley E, Pratt R, Dougall N, et al. The Patient Centred Assessment Method for improving nurse-led biopsychosocial assessment of patients with long-term conditions: a feasibility RCT. NIHR J Lib. 2018;1:1.
Poverty: a clinical tool for primary care providers. Mississauga: Centre for Effective Practice; 2016. Available from: https://cep.health/clinical-products/poverty-a-clinical-tool-for-primary-care-providers/. Accessed 17 Sept 2021.
Total health assessment questionnaire for medicare members. Kaiser Foundation Health Plan, Inc; 2013. Available from: https://sirenetwork.ucsf.edu/tools-resources/resources/total-health-assessment-questionnaire-medicare-members. Accessed 17 Sept 2021.
Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE project. Pediatrics. 2007;120(3):547–58.
Page-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, Ianakieva V, et al. Addressing social determinants of health in a clinic setting: the WellRx pilot in Albuquerque, New Mexico. J Am Board Fam Med. 2016;29(3):414–8.
Sundar KR. Universal screening for social needs in a primary care clinic: a quality improvement approach using the your current life situation survey. Perm. 2018;22:18–089.
Gottlieb L, Hessler D, Long D, Amaya A, Adler N. A randomized trial on screening for social determinants of health: the iScreen study. Pediatrics. 2014;134(6):E1611–E8.
Sokol R, Austin A, Chandler C, Byrum E, Bousquette J, Lancaster C, et al. Screening children for social determinants of health: a systematic review. Pediatrics. 2019;144(4):e20191622.
Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–304.
Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med. 2011;2011:812182.
Reves SR, O'Neal JP, Gonzalez MM, McHenry C, Favour M, Etz RS. A 60-second survey to identify patients’ unmet social needs. Ann Fam Med. 2019;17(3):274.
Vest JR, Grannis SJ, Haut DP, Halverson PK, Menachemi N. Using structured and unstructured data to identify patients’ need for services that address the social determinants of health. Int J Med Inf. 2017;107:101–6.
Vest JR, Menachemi N, Grannis SJ, Ferrell JL, Kasthurirathne SN, Zhang Y, et al. Impact of risk stratification on referrals and uptake of wraparound services that address social determinants: a stepped wedged trial. Am J Prev Med. 2019;56(4):e125–e33.
Wallace AS, Luther B, Guo JW, Wang CY, Sisler S, Wong B. Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018. Prev Chronic Dis. 2020;17:E45.
Selvaraj K, Ruiz MJ, Aschkenasy J, Chang JD, Heard A, Minier M, et al. Screening for toxic stress risk factors at well-child visits: the addressing social key questions for health study. J Pediatr. 2019;205:244–9.e4.
Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children--outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24(3):1063–73.
Regenstein M, Trott J, Williamson A, Theiss J. Addressing social determinants of health through medical-legal partnerships. Health Aff. 2018;37(3):378–85.
DeJong NA, Wood CT, Morreale MC, Ellis C, Davis D, Fernandez J, et al. Identifying social determinants of health and legal needs for children with special health care needs. Clin Pediatr (Phila). 2016;55(3):272–7.
Taylor DR, Bernstein BA, Carroll E, Oquendo E, Peyton L, Pachter LM. Keeping the heat on for children’s health: a successful medical-legal partnership initiative to prevent utility shutoffs in vulnerable children. J Health Care Poor Underserved. 2015;26(3):676–85.
Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care. Health Justice Prog. 2019;65(4):246–8.
Legal health check-up: Legal Health Check-Up. Available from: https://legalhealthcheckup.ca/en/. Accessed 17 Sept 2021.
National Center for Medical-Legal Partnership. Washington, DC: National Center Initiatives. Available from: https://medical-legalpartnership.org/impact/initiatives/. Accessed 17 Sept 2021.
Marple K. Using the law to inform empowered patient care in Austin. Washington, DC: National Center for Medical-Legal Partnership; 2018.
Lawton R, Whitehead M, Henize A, Fink E, Salamon M, Kahn R, et al. Medical-legal-psychology partnerships - innovation in addressing social determinants of health in pediatric primary care. Acad Pediatr. 2020;19:19.
Weintraub DMD, Rodgers MAJD, Botcheva LP, Loeb ABA, Knight RJD, Ortega KMA, et al. Pilot study of medical-legal partnership to address social and legal needs of patients. J Health Care Poor Underserved. 2010;21(2):157–68.
Social Interventions Research & Evaluation Network. Social need screening tools comparison table. Available from: https://sirenetwork.ucsf.edu/tools-resources/resources/screening-tools-comparison-tables. Accessed 17 Sept 2021.
Tobin Tyler E. Medical-legal partnership in primary care: moving upstream in the clinic. Am J Lifestyle Med. 2019;13(3):282–91.
Greasley P, Small N. Establishing a welfare advice service in family practices: views of advice workers and primary care staff. Fam Pract. 2005;22(5):513–9.
Hassan A, Scherer EA, Pikcilingis A, Krull E, McNickles L, Marmon G, et al. Improving social determinants of health: effectiveness of a web-based intervention. Am J Prev Med. 2015;49(6):822–31.
Coppel DH, Packham CJ, Varnam MA. Providing welfare rights advice in primary care. Public Health. 1999;113(3):131–5.
Hoskins R, Tobin J, McMaster K, Quinn T. Roll-out of a nurse-led welfare benefits screening service throughout the largest local health care co-operative in Glasgow: an evaluation study. Public Health. 2005;119(10):853–61.
Hoskins RA, Smith LN. Nurse-led welfare benefits screening in a general practice located in a deprived area. Public Health. 2002;116(4):214–20.
Moffatt S, Mackintosh J, White M, Howel D, Sandell A. The acceptability and impact of a randomised controlled trial of welfare rights advice accessed via primary health care: qualitative study. BMC Public Health. 2006;6:163.
Toeg D, Mercer L, Iliffe S, Lenihan P. Proactive, targeted benefits advice for older people in general practice: a feasibility study. Health Soc Care Community. 2003;11(2):124–8.
Greasley P, Small N. Providing welfare advice in general practice: referrals, issues and outcomes. Health Soc Care Community. 2005;13(3):249–58.
Powell JE, Langley C, Kirwan J, Gubbay D, Memel D, Pollock J, et al. Welfare rights services for people disabled with arthritis integrated in primary care and hospital settings: set-up costs and monetary benefits. Rheumatology (Oxford). 2004;43(9):1167–72.
Abbott S, Hobby L, Cotter S. What is the impact on individual health of services in general practice settings which offer welfare benefits advice? Health Soc Care Community. 2005;14(1):1–8.
Mackintosh J, White M, Howel D, Chadwick T, Moffatt S, Deverill M, et al. Randomised controlled trial of welfare rights advice accessed via primary health care: pilot study [ISRCTN61522618]. BMC Public Health. 2006;6(1):162.
Parry J. Practising equity-focused health care. How St. Michael’s Hospital Academic Family Health Team works to address the social determinants of health. St. Michael’s Academic Family Health Team. 2020.
Unity Health Toronto. Social determinants of health. Available from: https://unityhealth.to/social-determinants-of-health/. Accessed 17 Sept 2021.
Pinto AD, Glattstein-Young G, Mohamed A, Bloch G, Leung F-H, Glazier RH. Building a foundation to reduce health inequities: routine collection of sociodemographic data in primary care. J Am Board Fam Med. 2016;29(3):348–55.
Pinto AD, Bloch G. Framework for building primary care capacity to address the social determinants of health. Can Fam Physician. 2017;63(11):e476–e82.
Collins PA, Resendes SJ, Dunn JR. The untold story: examining Ontario’s Community Health Centres’ initiatives to address upstream determinants of health. Healthc Policy. 2014;10(1):14–29.
Rx Community: social prescribing. Alliance for Healthier Communities. Available from: https://www.allianceon.org/Social-Prescribing. Accessed 17 Sept 2021.
Mulligan K. Director of Policy and Communications, Alliance for Healthier Communities. Personal communication. 30th September 2019.
Mulligan K, Hsiung S, Bhatti S, Rehel J, Rayner J. Social prescribing in Ontario final report. Toronto: Alliance for Healthier Communities; 2020.
Bromley by Bow Centre. Supporting you to find work. London: 2020. Available from: https://www.bbbc.org.uk/services/find-work/. Accessed 17 Sept 2021.
Cannon L, Ferguson K. Key findings from the tower hamlets social prescribing survey 2017. London: Tower Hamlets Together; 2018.
Deep End Project. Deep end manifesto 2017. Glasgow: Deep End Project; 2017.
Watt GC. The exceptional potential of general practice. Boca Raton: CRC Press; 2019.
Sinclair J. Policy in practice. London: Policy in Practice; 2018. Available from: http://policyinpractice.co.uk/glasgows-deep-end-advice-worker-project-improving-accessibility-of-advice-services/
Sinclair J. The deep end advice worker project: embedding an advice worker in general practice settings. Glasgow: Glasgow Centre for Population Health; 2017.
Pinto AD, Hassen N, Craig-Neil A. Employment interventions in health settings: a systematic review and synthesis. Ann Fam Med. 2018;16(5):447–60.
Seligman HK, Jacobs EA, López A, Tschann J, Fernandez A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care. 2012;35(2):233–8.
Bahadur K, Pai S, Thoby E, Petrova A. Frequency of food insecurity and associated health outcomes in pediatric patients at a federally qualified health center. J Community Health. 2018;43(5):896–900.
Leonard T, Hughes AE, Donegan C, Santillan A, Pruitt SL. Overlapping geographic clusters of food security and health: where do social determinants and health outcomes converge in the U.S? SSM Popul Health. 2018;5:160–70.
Adams E, Hargunani D, Hoffmann L, Blaschke G, Helm J, Koehler A. Screening for food insecurity in pediatric primary care: a clinic’s positive implementation experiences. J Health Care Poor Underserved. 2017;28(1):24–9.
Council on Community Pediatrics and Committee on Nutrition. Promoting food security for all children. Pediatrics. 2015;136(5):e1431–e8.
Robinson T, Bryan L, Johnson V, McFadden T, Lazarus S, Simon HK. Hunger: a missed opportunity for screening in the pediatric emergency department. Clin Pediatr (Phila). 2018;57(11):1318–25.
Beck AF, Henize AW, Kahn RS, Reiber KL, Young JJ, Klein MD. Forging a pediatric primary care-Community partnership to support food-insecure families. Pediatrics. 2014;134(2):E564–E71.
Cullen D, Woodford A, Fein J. Food for thought: a randomized trial of food insecurity screening in the emergency department. Acad Pediatr. 2019;19(6):646–51.
Makelarski JA, Abramsohn E, Benjamin JH, Du SX, Lindau ST. Diagnostic accuracy of two food insecurity screeners recommended for use in health care settings. Am J Public Health. 2017;107(11):1812–7.
Gattu RK, Paik G, Wang Y, Ray P, Lichenstein R, Black MM. The hunger vital sign identifies household food insecurity among children in emergency departments and primary care. Children (Basel). 2019;6(10):02.
Pooler JA, Hoffman VA, Karva FJ. Primary care providers’ perspectives on screening older adult patients for food insecurity. J Aging Soc Policy. 2018;30(1):1–23.
Knowles M, Khan S, Palakshappa D, Cahill R, Kruger E, Poserina BG, et al. Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. J Health Care Poor Underserved. 2018;29(1):181–91.
Chiu S, Okafor M. Challenges and strategies in the implementation of a two-item food insecurity screening tool in primary care. Educ Prim Care. 2019;30(1):52–4.
Palakshappa D, Doupnik S, Vasan A, Khan S, Seifu L, Feudtner C, et al. Suburban families’ experience with food insecurity screening in primary care practices. Pediatrics. 2017;140(1):e20170320.
Palakshappa D, Goodpasture M, Albertini L, Brown CL, Montez K, Skelton JA. Written versus verbal food insecurity screening in one primary care clinic. Acad Pediatr. 2020;20(2):203–7.
Barnidge E, LaBarge G, Krupsky K, Arthur J. Screening for food insecurity in pediatric clinical settings: opportunities and barriers. J Community Health. 2017;42(1):51–7.
De Marchis E, Fichtenberg C, Gottlieb L. Food insecurity interventions in health care settings: a review of the evidence. San Francisco: University of California, San Francisco Social Interventions Research & Evaluation Network; 2020.
De Marchis EH, Torres JM, Benesch T, Fichtenberg C, Allen IE, Whitaker EM, et al. Interventions addressing food insecurity in health care settings: a systematic review. Ann Fam Med. 2019;17(5):436–47.
Collins P, Power E, Little M. Municipal-level responses to household food insecurity in Canada: a call for critical, evaluative research. Canad J Public Health. 2014;105(2):e138–e41.
Chung RYN, Chung GKK, Gordon D, et al. Housing affordability effects on physical and mental health: household survey in a population with the world’s greatest housing affordability stress. J Epidemiol Community Health. 2020;74:164–72.
Popay J, Kowarzik U, Mallinson S, Mackian S, Barker J. Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part II: lay perspectives. J Epidemiol Community Health. 2007;61(11):972–7.
Driving innovative health care solutions for underserved populations. Association of American Medical Colleges; 2019. Available from: https://www.aamc.org/news-insights/driving-innovative-health-care-solutions-underserved-populations. Accessed 17 Sept 2021.
Better Health through housing. University of Illinois Health. Available from: https://hospital.uillinois.edu/about-ui-health/community-commitment/better-health-through-housing. Accessed 17 Sept 2021.
Losonczy LI, Hsieh D, Wang M, Hahn C, Trivedi T, Rodriguez M, et al. The Highland Health Advocates: a preliminary evaluation of a novel programme addressing the social needs of emergency department patients. Emerg Med J. 2017;34(9):599–605.
McGuire J, Bikson K, Blue-Howells J. How many social workers are needed in primary care? A patient-based needs assessment example. Health Soc Work. 2005;30(4):305–13.
O'Brien KH. Social determinants of health: the how, who, and where screenings are occurring; a systematic review. Soc Work Health Care. 2019;58(8):719–45.
Oldfield BJ, Casey M, DeCew A, Morales SI, Olson DP. Screening for social determinants of health among children: patients’ preferences for receiving information to meet social needs and a comparison of screening instruments. Popul Health Manag. 2020;25:25.
Higginbotham K, Davis Crutcher T, Karp SM. Screening for social determinants of health at well-child appointments: a quality improvement project. Nurs Clin N Am. 2019;54(1):141–8.
Tong ST, Liaw WR, Kashiri PL, Pecsok J, Rozman J, Bazemore AW, et al. Clinician experiences with screening for social needs in primary care. J Am Board Fam Med. 2018;31(3):351–63.
Chhabra M, Sorrentino AE, Cusack M, Dichter ME, Montgomery AE, True G. Screening for Housing instability: providers’ reflections on addressing a social determinant of health. J Gen Intern Med. 2019;34(7):1213–9.
Coughlin SS, Mann P, Vernon M, Young L, Ayyala D, Sams R, et al. A logic framework for evaluating social determinants of health interventions in primary care. J Hosp Manag Health Policy. 2019;3:23.
Klein MD, Kahn RS, Baker RC, Fink EE, Parrish DS, White DC. Training in social determinants of health in primary care: does it change resident behavior? Acad Pediatr. 2011;11(5):387–93.
Patel M, Bathory E, Scholnick J, White-Davis T, Choi J, Braganza S. Resident documentation of social determinants of health: effects of a teaching tool in the outpatient setting. Clin Pediatr (Phila). 2018;57(4):451–6.
Bradley KJ, Wros P, Bookman N, Mathews LR, Voss H, Ostrogorsky TL, et al. The Interprofessional Care Access Network (I-CAN): achieving client health outcomes by addressing social determinants in the community. J Interprof Care. 2018:1–8.
Clark CR, Baril N, Kunicki M, Johnson N, Soukup J, Ferguson K, et al. Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women’s Health Demonstration Project. J Women’s Health (Larchmt). 2009;18(5):677–90.
Greasley P. Welfare advice in general practice: a resource for community nurses. Br J Community Nurs. 2005;10(8):368–72.
Kranz AM, Mahmud A, Agniel D, Damberg C, Timbie JW. Provision of social services and health care quality in US community health centers, 2017. Am J Public Health. 2020;110(4):567–73.
Sandel M, Hansen M, Kahn R, Lawton E, Paul E, Parker V, et al. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff. 2010;29(9):1697–705.
Parker D. Housing as an intervention on hospital use: access among chronically homeless persons with disabilities. J Urban Health. 2010;87(6):912–9.
Reynolds K, Allen EH, Fedorowicz M, Ovalle J. Affordable housing investment a guide for nonprofit hospitals and health systems. Washington, DC: Urban Institute; 2019.
Grant K. Toronto-based hospital network commits land to build affordable housing. Toronto: The Globe and Mail; 2019.
Hawryluk M. Why hospitals are getting into the housing business. Kaiser Health News; 2019. Available from: https://khn.org/news/why-hospitals-are-getting-into-the-housing-business/.
Flaccus G. 6 Portland health providers give $21.5M for homeless housing. Washington, D.C: US News & World Report; 2016.
Bartolone P. Hospitals step in to help house the homeless. will it make a difference? Menlo Park: California Healthline; 2017.
Hospital to housing. St Louis: St Patrick Center; 2019. Available from: http://stpatrickcenter.org/hospital-to-housing/. Accessed 17 Sept 2021.
Cohn M. Bon Secours joins effort to build, sustain affordable housing projects. Baltimore: The Baltimore Sun; 2019.
De Marchis EH, Hessler D, Fichtenberg C, Adler N, Byhoff E, Cohen AJ, et al. Part I: a quantitative study of social risk screening acceptability in patients and caregivers. Am J Prev Med. 2019;57(6 Suppl 1):S25–37.
Orr CJ, Chauvenet C, Ozgun H, Pamanes-Duran C, Flower KB. Caregivers’ experiences with food insecurity screening and impact of food insecurity resources. Clin Pediatr (Phila). 2019;58(14):1484–92.
Rogers AJ, Hamity C, Sharp AL, Jackson AH, Schickedanz AB. Patients’ attitudes and perceptions regarding social needs screening and navigation: multi-site survey in a large integrated health system. J Gen Intern Med. 2020;35(5):1389–95.
Byhoff E, De Marchis EH, Hessler D, Fichtenberg C, Adler N, Cohen AJ, et al. Part II: a qualitative study of social risk screening acceptability in patients and caregivers. Am J Prev Med. 2019;57(6 Suppl 1):S38–46.
Jaganath D, Johnson K, Tschudy MM, Topel K, Stackhouse B, Solomon BS. Desirability of clinic-based financial services in urban pediatric primary care. J Pediatr. 2018;202:285–90.
Hsu C, Cruz S, Placzek H, Chapdelaine M, Levin S, Gutierrez F, et al. Patient perspectives on addressing social needs in primary care using a screening and resource referral intervention. J Gen Intern Med. 2020;35(2):481–9.
Swamy P, Monterrey AC, Wood MS, Troisi CL, Greeley CS. Caregiver and pediatric health care provider views on social needs identification. J Prim Care Community Health. 2020;11:2150132720923085.
Byhoff E, Garg A, Pellicer M, Diaz Y, Yoon GH, Charns MP, et al. Provider and staff feedback on screening for social and behavioral determinants of health for pediatric patients. J Am Board Fam Med. 2019;32(3):297–306.
Lewis JH, Whelihan K, Navarro I, Boyle KR, Team SDHCSI. Community health center provider ability to identify, treat and account for the social determinants of health: a card study. BMC Fam Pract. 2016;17:121.
Ward A, Asif A, Cattermole R, Chima J, Ebbatson T, Mahi I, et al. Social prescribing by students: the design and delivery of a social prescribing scheme by medical students in general practice. Educ Prim Care. 2020;31(5):318-22.
Purkey E, Bayoumi I, Coo H, Maier A, Pinto AD, Olomola B, et al. Exploratory study of “real world” implementation of a clinical poverty tool in diverse family medicine and pediatric care settings. Int J Equity Health. 2019;18(1):200.
Schickedanz A, Hamity C, Rogers A, Sharp AL, et al. Clinician experiences and attitudes regarding screening for social determinants of health in a large integrated health system. Med Care. 2019;57(Suppl 6 2):S197.
Babbel B, Mackenzie M, Hastings A, Watt G. How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care. Crit Public Health. 2019;29(2):168–80.
Fiori K, Patel M, Sanderson D, Parsons A, Hodgson S, Scholnick J, et al. From policy statement to practice: integrating social needs screening and referral assistance with community health workers in an urban academic health center. J Prim Care Community Health. 2019;10:2150132719899207.
Gold R, Bunce A, Cowburn S, Dambrun K, Dearing M, Middendorf M, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018;16(5):399–407.
Meyer D, Lerner E, Phillips A, Zumwalt K. Universal screening of social determinants of health at a large US Academic Medical Center, 2018. Am J Public Health. 2020;110(S2):S219–S21.
Southby K, Gamsu M. Factors affecting general practice collaboration with voluntary and community sector organisations. Health Soc Care Community. 2018;26(3):e360–e9.
Williams-Roberts H, Neudorf C, Abonyi S, Cushon J, Muhajarine N. Facilitators and barriers of sociodemographic data collection in Canadian health care settings: a multisite case study evaluation. Int J Equity Health. 2018;17(1):186.
Bloch G, Rozmovits L, Giambrone B. Barriers to primary care responsiveness to poverty as a risk factor for health. BMC Fam Pract. 2011;12(1):62.
Valaitis R, Cleghorn L, Ploeg J, Risdon C, Mangin D, Dolovich L, et al. Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study. BMC Fam Pract. 2020;21(1):69.
Messmer E, Brochier A, Joseph M, Tripodis Y, Garg A. Impact of an on-site versus remote patient navigator on pediatricians’ referrals and families’ receipt of resources for unmet social needs. J Prim Care Community Health. 2020;11:2150132720924252.
Moffatt S, Steer M, Lawson S, Penn L, O'Brien N. Link worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions. BMJ Open. 2017;7(7):e015203.
Mercer SW, Fitzpatrick B, Grant L, Chng NR, McConnachie A, Bakhshi A, et al. Effectiveness of community-links practitioners in areas of high socioeconomic deprivation. Ann Fam Med. 2019;17(6):518–25.
Sege R, Preer G, Morton SJ, Cabral H, Morakinyo O, Lee V, et al. Medical-legal strategies to improve infant health care: a randomized trial. Pediatrics. 2015;136(1):97–106.
Frostick C, Bertotti M. The frontline of social prescribing - how do we ensure Link Workers can work safely and effectively within primary care? Chronic Illness. 2019. https://doi.org/10.1177/1742395319882068.
Herrera CN, Brochier A, Pellicer M, Garg A, Drainoni ML. Implementing social determinants of health screening at community health centers: clinician and staff perspectives. J Prim Care Community Health. 2019;10:2150132719887260.
Kung A, Cheung T, Knox M, Willard-Grace R, Halpern J, Olayiwola JN, et al. Capacity to address social needs affects primary care clinician burnout. Ann Fam Med. 2019;17(6):487–94.
Pantell MS, De Marchis E, Bueno A, Gottlieb LM. Practice capacity to address patients’ social needs and physician satisfaction and perceived quality of care. Ann Fam Med. 2019;17(1):42–5.
Krska J, Palmer S, Dalzell-Brown A, Nicholl P. Evaluation of welfare advice in primary care: effect on practice workload and prescribing for mental health. Prim Health Care Res Dev. 2013;14(3):307–14.
Hsu C, Hertel E, Johnson E, Cahill C, Lozano P, Ross TR, et al. Evaluation of the learning to integrate neighborhoods and clinical care project: findings from implementing a New lay role into primary care teams to address social determinants of health. Perm. 2018;22:18–101.
Garg A, Sarkar S, Marino M, Onie R, Solomon BS. Linking urban families to community resources in the context of pediatric primary care. Patient Educ Couns. 2010;79(2):251–4.
Wildman JM, Moffatt S, Penn L, O'Brien N, Steer M, Hill C. Link workers’ perspectives on factors enabling and preventing client engagement with social prescribing. Health Soc Care Community. 2019;27(4):991–8.
Poverty and child health in the United States. Pediatrics. 2016:peds.2016–0339.
Daniel H, Bornstein S, Kane G, Physicians ftHaPPCotACo. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians Position Paper. Ann Intern Med. 2018;168(8):577–8.
Butkus R, Rapp K, Cooney TG, Engel LS. Envisioning a better U.S. health care system for all: reducing barriers to care and addressing social determinants of health. Ann Intern Med. 2020;172(2_Supplement):S50–S9.
Futures. IfA. Community health centers leveraging the social determinants of health. Alexandria: Institute for Alternative Futures; 2012.
Human Rescources & Services Administration. Federally qualified health centers. Available from: https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html. Accessed 17 Sept 2021.
Draayer A. Integrating social health data to improve care delivery and address social needs. Boston: Health Leads; 2018.
Garg A, Butz AM, Dworkin PH, Lewis RA, Serwint JR. Screening for basic social needs at a medical home for low-income children. Clin Pediatr (Phila). 2009;48(1):32–6.
Chung EK, Siegel BS, Garg A, Conroy K, Gross RS, Long DA, et al. Screening for social determinants of health among children and families living in poverty: a guide for clinicians. Curr Probl Pediatr Adolesc Health Care. 2016;46(5):135–53.
Garg A, Marino M, Vikani AR, Solomon BS. Addressing families’ unmet social needs within pediatric primary care: the health leads model. Clin Pediatr (Phila). 2012;51(12):1191–3.
Moffett ML, Kaufman A, Bazemore A. Community health workers bring cost savings to patient-centered medical homes. J Community Health. 2018;43(1):1–3.
Huffstetler AN, Phillips RL Jr. Payment structures that support social care integration with clinical care: social deprivation indices and novel payment models. Am J Prev Med. 2019;57(6 Suppl 1):S82–S8.
Pruitt Z, Emechebe N, Quast T, Taylor P, Bryant K. Expenditure reductions associated with a social service referral program. Popul Health Manag. 2018;21(6):469–76.
Schickedanz A, Sharp A, Hu YR, Shah NR, Adams JL, Francis D, et al. Impact of social needs navigation on utilization among high utilizers in a large integrated health system: a quasi-experimental study. J Gen Intern Med. 2019;34(11):2382–9.
Vasan A, Morgan JW, Mitra N, Xu C, Long JA, Asch DA, et al. Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials. Health Serv Res. 2020;08:08.
Fiori KP, Heller CG, Rehm CD, Parsons A, Flattau A, Braganza S, et al. Unmet social needs and no-show visits in primary care in a US northeastern urban health system, 2018-2019. Am J Public Health. 2020;110:S242–S50.
Gottlieb L, Ackerman S, Wing H, Manchanda R. Understanding Medicaid managed care investments in members’ social determinants of health. Popul Health Manag. 2017;20(4):302–8.
The accountable health communities health-related social needs screening tool. In: Services CfMM, editor.: Centers for Medicare & Medicaid Services.
Gottlieb LM, Quinones-Rivera A, Manchanda R, Wing H, Ackerman S. States’ influences on medicaid investments to address patients’ social needs. Am J Prev Med. 2017;52(1):31–7.
Gottlieb L, Razon N, Aboelata N. How do safety net clinics pay for social care programs? 2019.
Harding R, Sherr L, Sherr A, Moorhead R, Singh S. Welfare rights advice in primary care: prevalence, processes and specialist provision. Fam Pract. 2003;20(1):48–53.
Parry J. A prescription for poverty. Br Med J. 2016;353:i3370.
Buitron de la Vega P, Losi S, Sprague Martinez L, Bovell-Ammon A, Garg A, James T, et al. Implementing an EHR-based screening and referral system to address social determinants of health in primary care. Med Care. 2019;57(Suppl 6 Suppl 2):S133–S9.
Cantor MN, Thorpe L. Integrating data on social determinants of health into electronic health records. Health Aff. 2018;37(4):585–90.