ROOTS Program Portal

Employment Resources

  1. Employment Risk Survey Questions – The Petaluma Health Center team has developed an example of follow on survey questions for patients who identify on PRAPARE as having employment risk.

Food Security Resources

  1. Addressing Food Insecurity in Health Care Settings: Key Actions & Tools for Success: Children’s HealthWatch, Feeding America, and the Food Research & Action Center (FRAC) have identified four key actions and multiple resources for successful efforts in this brief.
  2. Addressing Social Determinants of Health: Navigating Contract Development & Launch: This webinar will feature a panel discussion with Lutheran Social Services of North Dakota & Lutheran Social Services Housing and Project Angel Food, two organizations currently engaged in innovative, outcomes-oriented, statewide contracts to improve the health of their communities.
  3. CA4Health Perspectives Virtual Meet-Up: Food Justice: Tune in to this virtual meet-up to hear from CA4Health members on the Food Justice landscape, from state policy to local efforts addressing food security and food systems.
  4. NACHC Food Insecurity ResourcesNACHC, with support from the Medtronic Foundation, released Community Health Centers as Food Oasis Partners: Addressing Food Insecurity for Patients and Communities to understand the depth and breadth of what health centers do every day to assure their patients and communities have access to nutritious food. Check out featured case studies, potential food partners, recommendations on getting started on your own food insecurity program, and food oasis glossary.

Incarceration Resources

Stay tuned for resources!

Partnership Resources

  1. Cross-Sector Data Partnerships – The National Center for Complex Health and Social Needs recently hosted a 3-part webinar series on cross-sector data partnerships. Click here to view slides, the recordings, and Q&A from their most recent webinar “Activating Shared Data.”
  2. The Northeast Valley Health Corporation team has shared some examples of MOUs they have with the following partners:
    • Schools – Their Champions for Change Program staff are providing edible garden activities and Supplemental Nutrition Assistance Program-Education(SNAP-Ed) for students and parents at the school sites. They are also evaluating the programs and they have allowed us to collect de-identified data.
    • Community Garden – They are going to rent garden plots and hold workshops for patients/participants and food swaps.
    • LA Care Family Resource Center – They will provide SNAP – Education, refer patients/participants to their on-site DPSS worker for assistance with enrolling in SNAP benefits, and build an edible garden/hold food swaps here.
  3. Report on Partnerships Between Health Care Institutions and CBOs: New York Academy of Medicine & Greater New York Hospital Association recently published a report on their research on partnerships between health care and community-based organizations in New York City.

Multi-SDOH Resources

  1. All In: Data for Community Health has a newsletter, where they share articles and webinar opportunities.
  2. California Improvement Network: Addressing Social Needs That Impact Health: This resource page from the California Improvement Network (CIN) consists of a short list of relevant and timely resources to help health care organizations in this complex endeavor, regardless of the organization’s history of effort and investment.
  3. California Improvement Network Connections, Summer 2018: Beyond the Exam Room: CIN launched a new partner meeting report, which aims to provide health care leaders with relevant information to address social needs. It includes six lessons from Kaiser Permanente, case studies from three leading organizations, and challenges and opportunities for CIN in this arena moving forward.
  4. Collaborative to Advance Social Health Integration: HealthLeads launched this interactive, 18-month program has brought together an amazing diversity of care teams that work together to learn and develop effective strategies to expand existing social health interventions.
  5. Health Leads Prepare 101: Integrating Social Needs Strategy Into Patient Care – On November 2, Health Leads shared valuable insights on the value of and key considerations in implementing social needs interventions in clinical settings. Click here to access the slides and recording from the webinar. See slides 29 & 30 for ideas about getting buy-in!
  6. Health Leads Social Needs Roadmap – Health Leads recently developed a framework to guide and support fellow health system and community leaders working to establish or expand effective social needs interventions.
  7. Hollywood, Health Equity & the Power of Your Stories to Make Positive Change: HealthBegins lays out strategies for identifying high-impact stories in health equity and setting them in the spotlight. They also outline how inclusion clauses can work in health care — and how HealthBegins is already employing them in this webinar.
  8. Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case: This new guidebook from The Commonwealth Fund breaks down the business case for investing in social services into six practical steps, and includes sample business cases and spotlights from the field.
  9. Open Call for Consumer Scholars: Putting Care at the Center 2018: Putting Care at the Center is the central event for the emerging field of complex care. The National Center is welcoming Consumer Scholars from organizations across the country to share their lived experiences and valuable insights on how to improve our broken system.
  10. Putting Care at the Center Conference Resources: Review the workshop slides, handouts and resources from the conference.
  11. Risk/Reward Calculation Strategies: In this webinar and blog, HealthBegins reviews risk/reward calculation strategies to help organizations identify the optimal, most efficient payment models to ensure that financial risks and rewards are appropriately understood and shared between clinical and community partners as they address health-related social needs.
  12. SDOH 101 for Health Care – The National Academy of Medicine Culture of Health Program hosted a public meeting on November 9 to engage allies in the culture of health movement. They posted many resources from that meeting, including a recent article “Social Determinants of Health 101 for Health Care” which is a good, short article to share with providers and other staff at your organizations. They also highlight the work of the Cincinnati’s Children’s Hospital!
  13. SDOH ROI Calculator for Partnerships: This financial tool will calculate the return on investment from integrating social services with medical care. The calculator will compare how the financial returns and risks could be divided between the cross-sectional partners (social service and medical) under a variety of payment arrangements and levels.
  14. Social Determinants of Health Academy: The Social Determinants of Health (SDOH) Academy is a 6-month HRSA-funded virtual training series designed to help staff from health centers, health center controlled networks, and primary care associations develop, implement, and sustain SDOH interventions in their clinics and communities. Check out the webinars and virtual office hours they have planned between January-June 2018; webinars are open to all who register free of charge.
  15. SIREN Tools and Resources – The SIREN website includes reports, issue briefs, and commentaries on relevant topics, social and economic determinants screening tools, webinars and presentations that have been conducted in the SDOH field.
  16. State of the Science: A National Research Meeting on Medical & Social Care Integration: SIREN, OCHIN, and Kaiser Permanente Center for Health Research are excited to announce the first national conference devoted to research on medical and social care integration in health care delivery settings on Feb. 4-5, 2019.
  17. Workflow Models and Strategies to Collect Standardized Data on the Social Determinants of Health Using PRAPARE: NACHC recently hosted a session on how to best develop a workflow for collecting standardized SDOH data using PRAPARE.

Social Needs Project Case Studies

Northeast Valley Health Corporation focused on screening and referring for food insecurity, a top social risk for its patient population, in patients 12 through 17 years of age at two of its clinical sites.
Asian Health Services saw an opportunity to expand its PRAPARE work and improve its response to the needs surfaced through screenings.
LifeLong Medical Care used the ROOTS grant to pilot a food insecurity screening and referral intervention in one primary care clinic with the goal of eventually expanding systemwide.
LAC+USC worked to integrate patient social and behavioral health needs into primary care clinics in the late spring of 2016. With the ROOTS grant, the team saw an opportunity to improve food and housing insecurity risk screening, documentation, and workflows, as well as to expand beyond the clinic walls and connect the work on a community level.
Petaluma Health Center worked to strengthen their PRAPARE implementation and foster strategic partnerships to develop job training and employment services for under- or unemployed patients.
St. John’s used the ROOTS grant opportunity to develop and refine their RISE program. RISE (Re-entry Integrated Services, Engagement & Empowerment), which was launched in the fall of 2017, provides intensive health and social needs case management to individuals with chronic health conditions transitioning from jail or prison back into the community.
The Center for Care Innovations selected West County Health Centers as one of seven organizations to participate in Roles Outside of Traditional Systems, or ROOTS, a one-year learning collaborative f...