Toolkits
Toolkits synthesize evidence into a digestible and actionable format.
We’ll continue to update this page with more toolkits highlighting primary care evidence.
Social Needs Referrals in Primary Care: An Implementation Toolkit
As social risk screening increasingly becomes standard in primary care settings, upfront planning is required to connect patients to needed community resources, maintain up-to date information about available resources, and develop and adopt optimal workflows to support patients with getting their social needs met through community referrals.
This is a pragmatic, evidence-based toolkit intended to be used by clinic leaders, administrators, and staff to create or refine social needs referral-making and related activities in primary care settings. This toolkit provides an opportunity for clinic staff to learn and collaborate with each other. Drawing on results from prior research, the toolkit can help primary care teams make four key decisions to design social needs referral programs that are relevant to their unique contexts.
Social Needs Referrals in Primary Care: An Implementation Toolkit [PDF]
Implementation Materials
- Social Needs Referrals Orientation Template [PPT]
- Referral Goals Thermometer Template [Excel]
- Referral Outcomes Thermometer Template [Excel]
- PDSA Worksheet Template (PDF)
- Certificate of Recognition Template (PDF)
The toolkit was developed as a collaborative effort across four Implementation Science Centers in Cancer Control (ISC3) (Oregon Health & Science University and OCHIN BRIDGE-C2, Harvard ISCCCE, University of Washington OPTICC, and Washington University-ISC3) funded by the National Cancer Institute. Pilot testing of the toolkit was conducted in three diverse primary care clinics and further iterated based on pilot testing outcomes. The toolkit was also informed by the expertise of consulting partner, UCSF’s Social Interventions Research & Evaluation Network.
Suggested citation: Social Needs Referrals in Primary Care: An Implementation Toolkit. Oregon Health & Science University & OCHIN BRIDGE-C2, Washington University ISC3, Harvard University ISCCCE, Caring Health Center, University of Washington OPTICC; July 2024.
For questions related to this guide please contact: [email protected].
Guide to Implementing Social Risk Screening and Referral-Making
Adverse social determinants of health – referred to in this guide as social risks – include contextual factors such as food, transportation, and housing instability, and social isolation. Collecting information on these risks can help ambulatory care teams understand and address how these factors impact their patients’ health.
This pragmatic guide will help your clinic implement social risk screening and (if desired) referral-making, or improve your current practices. It is meant to be used by any primary / ambulatory care staff interested in implementing social risk screening and referral-making.
Overview: This guide uses a five-step roadmap for implementing or improving social risk screening and related activities at your clinic. It provides tools and materials to support each step, and a list of useful resources.
Introduction [PDF]
Step 1: Getting Ready [PDF]
Step 2: Identify Clinic Goals [PDF]
Step 3: Create a Social Risk Plan [PDF]
- Social Risk Screening and Data Collection Workflow Planning Tool [Excel]
- Social Risk Screening Workflow Rollout Planning Tool [Excel]
Step 4: Orient Clinic Staff to Your Clinic’s Social Risk Plan [PDF]
- Social Risk Screening Kick-Off / Staff Orientation Slide Deck [PowerPoint]
- Social Risk Screening Kick-Off Meeting Agenda [Word]
- Goals Thermometer [Excel]
- Certificate of Recognition [Word]
- Social Risk Screening Poster [PDF]
- Social Risk Screening Poster [PowerPoint]
Step 5: Roll Out and Iterate [PDF]
Resources to Support Implementing Social Risk Data Collection and Referral-making [PDF]
Guide to Implementing Social Risk Screening and Referral-making: Steps 1-5 [PDF]
Citation: Guide to implementing social risk screening and referral-making. Kaiser Permanente Center for Health Research and OCHIN, Inc. 2021.
For any questions related to this guide please email: [email protected].
Outpatient Clinic-Based Administration of COVID-19 Vaccines: Implementation Toolkit
Community-Based Administration of COVID-19 Vaccines: Implementation Toolkit
Well Being Trust Tool Bank
The Well Being Trust Tool Bank begins to build a bank of tools that can be used by grantees, staff, and other health system programs to enhance their approach to learning, assessment and planning of implementation programs and initiatives. As a resource for measuring implementation readiness, progress, and sustainability, each tool details who the resource is designed for as well as why and how to use it.
Dissemination & Implementation of evidence-based mental health and well-being strategies: The Well Being Trust Toolbox
The Well Being Trust Toolbox equips community leaders and decision makers with solutions and resources for improving mental health and well-being outcomes in their organizations and communities. The Toolbox is designed for health sector leaders (providers, payers, purchasers) as well as policymakers, philanthropy and community leaders. OHSU and Well Being Trust partners assembled evidence and tools to support organizations’ change process focused on a variety of issues, from integrating behavioral and physical health care with social needs to preventing suicide in youth and adults.
