This fragment is available on en/ImplementationGuide-hl7.fhir.us.sdoh-clinicalcare.html
This publication includes IP covered under the following statements.
| Type | Reference | Content |
|---|---|---|
| web | github.com | SDOH Clinical Care, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-sdoh-clinicalcare/ and changes regularly. See the Directory of published versions |
| web | www.iso.org |
ISO maintains the copyright on the country codes, and controls its use carefully. For further details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
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| web | ucum.org |
The UCUM codes, UCUM table (regardless of format), and UCUM Specification are copyright 1999-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. https://ucum.org/trac/wiki/TermsOfUse
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| web | www.regenstrief.org | This section describes standardized social risk assessment instruments, their benefits, and how to standardize their capture, coding and output leveraging work from the Regenstrief Institute and the National Library of Medicine (NLM), SDC Questionnaire , SDC QuestionnaireResponse , and StructureMap to automate the creation of SDOHCC Observation Screening Response and SDOHCC Condition instances from SDC QuestionnaireResponse . |
| web | www.socialworkers.org | Standardized assessment instruments are used to gather information about social risks and protective factors in a manner that is valid, reliable, and replicable without changes or adaptations to their structure and content. Within Gravity standards, standardized assessment instruments include both patient-completed questionnaires and formal, provider-completed decision-support instruments — ranging from brief questionnaires suitable for population-level screening to more in-depth instruments designed for thorough assessment of complex needs. The information collected through these instruments can be used by providers, public health organizations, and policymakers to develop interventions and programs aimed at addressing the root causes of health disparities and improving health outcomes for individuals and communities. However, per the National Association of Social Workers , standardized instruments — though useful — are a starting point for individualized assessment; they inform, but do not replace, the care team's direct interaction with the individual. |
| web | childrenshealthwatch.org | 2 Hunger Vital Sign™ Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., Cook, J. T., Ettinger de Cuba, S. A., Casey, P. H., Chilton, M., Cutts, D. B., Meyers A. F., Frank, D. A. (2010). Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity . Pediatrics, 126(1), 26-32. doi:10.1542/peds.2009-3146. |
| web | www.nachc.org | 3 Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE®) and its resources are proprietary information of the National Association of Community Health Centers (NACHC). For more information, visit https://www.nachc.org/resource/prapare/ . The example is included with permission. |
| web | github.com | Improved Rendering of all Capability Statements using tools and additional scripts . FHIR-40449 |
| web | github.com | Improved Rendering of all Capability Statements using tools and additional scripts . FHIR-40449 |
| web | cynchealth.org | We would like to thank CyncHealth , the Agency for Healthcare Research and Quality (AHRQ) , SIREN UCSF , and Larner College of Medicine at the University of Vermont for their support in developing this IG and all Gravity Project sponsors for their contributions to make rapid progress on the standardization of social determinants of health data. |
| web | sirenetwork.ucsf.edu | We would like to thank CyncHealth , the Agency for Healthcare Research and Quality (AHRQ) , SIREN UCSF , and Larner College of Medicine at the University of Vermont for their support in developing this IG and all Gravity Project sponsors for their contributions to make rapid progress on the standardization of social determinants of health data. |
| web | www.med.uvm.edu | We would like to thank CyncHealth , the Agency for Healthcare Research and Quality (AHRQ) , SIREN UCSF , and Larner College of Medicine at the University of Vermont for their support in developing this IG and all Gravity Project sponsors for their contributions to make rapid progress on the standardization of social determinants of health data. |
| web | www.ama-assn.org | AMA |
| web | www.elimu.io | Elimu |
| web | www.enablecare.us | EnableCare LLC |
| web | www.lantanagroup.com | Lantana Consulting Group |
| web | www.emiadvisors.net | EMI Advisors, LLC |
| web | dogwoodhealthconsulting.com | Dogwood Health Consulting |
| web | www.gevityinc.com | Gevity / Accenture |
| web | www.accenture.com | Gevity / Accenture |
| web | www.maxmddirect.com | MaxMD |
| web | www.maxmddirect.com | MaxMD |
| web | www.ama-assn.org | AMA |
| web | www.eatright.org | Academy of Nutrition and Dietetics |
| web | www.eatright.org | Academy of Nutrition and Dietetics |
| web | newwave.io | SAFFRON Labs |
| web | www.linkedin.com | Hausam Consulting LLC |
| web | www.mitre.org | MITRE |
| web | www.who.int |
World Health Organization. (n.d.). Social determinants of health
. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
World Health Organization. (2010). A conceptual framework for action on the social determinants of health . https://www.who.int/publications/i/item/9789241500852 |
| web | www.who.int |
World Health Organization. (n.d.). Social determinants of health
. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
World Health Organization. (2010). A conceptual framework for action on the social determinants of health . https://www.who.int/publications/i/item/9789241500852 |
| web | doi.org | Rodríguez-Violante, M., Hernández-Medrano, A. J., & Cervantes-Arriaga, A. (2024). The importance of standardized assessment. Movement Disorders Clinical Practice, 11 (Suppl. 3), S15–S20. https://doi.org/10.1002/mdc3.14085 |
| web | doi.org | Adapted from: Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinants of health lexicon for health care systems. The Milbank Quarterly, 97 (2), 407–419. https://doi.org/10.1111/1468-0009.12390 |
| web | cssp.org | Center for the Study of Social Policy. (2025). About Strengthening Families™ and the Protective Factors Framework . https://cssp.org/wp-content/uploads/2025/03/About-Strengthening-Families.pdf |
| web | www.civitasforhealth.org | Gravity Project, & Civitas Networks for Health. (2024). Social care co-design: Final report . Civitas Networks for Health. https://www.civitasforhealth.org/wp-content/uploads/2024/02/FINAL-Co-Design-Report-Gravity-Project-and-Civitas-Networks-for-Health.pdf |
| web | www.socialworkers.org | National Association of Social Workers. (2016). NASW standards for social work practice in health care settings . https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/NASW-Standards-for-Social-Work-Practice-in-Health-Care-Settings |
| web | chlpi.org |
Adapted from: Landauer, R., & Downer, S. (2022, January). HIPAA issue brief 4 of 5: Business associate arrangements
. Center for Health Law and Policy Innovation of Harvard Law School; GusNIP NTAE Center, Nutrition Incentive Hub. https://chlpi.org/wp-content/uploads/2022/02/hipaa-brief-4.pdf
U.S. Department of Health and Human Services, Office for Civil Rights. (2019, May 24). Business associates . https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html |
| web | sph.umich.edu |
National Community-Based Organization Network. (2004). What is a CBO?
University of Michigan School of Public Health. https://sph.umich.edu/ncbon/about/whatis.html
National Institutes of Health. (n.d.). Community-based organization (CBO) . HIV.gov Clinical Info Glossary. https://clinicalinfo.hiv.gov/en/glossary/community-based-organization-cbo |
| web | sirenetwork.ucsf.edu | Adapted from: Cartier, Y., Fichtenberg, C., & Gottlieb, L. (2019, April 16). Community resource referral platforms: A guide for health care organizations . Social Interventions Research & Evaluation Network (SIREN), University of California, San Francisco. https://sirenetwork.ucsf.edu/sites/default/files/wysiwyg/Community-Resource-Referral-Platforms-Guide.pdf |
| web | doi.org | Freeman, H. P., & Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117 (15 Suppl), 3537–3540. https://doi.org/10.1002/cncr.26262 |
| web | careers.naswwa.socialworkers.org | Adapted from: National Association of Social Workers Washington. (n.d.). Community resource navigator overview . https://careers.naswwa.socialworkers.org/career/community-resource-navigator |
| web | www.himss.org |
Adapted from: Office of the National Coordinator for Health Information Technology. (2026, May 7). Base electronic health record (EHR) definition
. U.S. Department of Health & Human Services. https://healthit.gov/certification-health-it/certification-criteria/base-electronic-health-record-definition/
Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care (Rev. ed.). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK233055/ Healthcare Information and Management Systems Society. (n.d.). Electronic health records . https://www.himss.org/library/ehr U.S. Code, 42 U.S.C. § 17921(5). https://www.law.cornell.edu/uscode/text/42/17921#5 International Organization for Standardization. (2011). Health informatics — Requirements for an electronic health record architecture (ISO 18308:2011). https://www.iso.org/standard/52823.html |
| web | www.law.cornell.edu |
Adapted from: Office of the National Coordinator for Health Information Technology. (2026, May 7). Base electronic health record (EHR) definition
. U.S. Department of Health & Human Services. https://healthit.gov/certification-health-it/certification-criteria/base-electronic-health-record-definition/
Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care (Rev. ed.). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK233055/ Healthcare Information and Management Systems Society. (n.d.). Electronic health records . https://www.himss.org/library/ehr U.S. Code, 42 U.S.C. § 17921(5). https://www.law.cornell.edu/uscode/text/42/17921#5 International Organization for Standardization. (2011). Health informatics — Requirements for an electronic health record architecture (ISO 18308:2011). https://www.iso.org/standard/52823.html |
| web | www.iso.org |
Adapted from: Office of the National Coordinator for Health Information Technology. (2026, May 7). Base electronic health record (EHR) definition
. U.S. Department of Health & Human Services. https://healthit.gov/certification-health-it/certification-criteria/base-electronic-health-record-definition/
Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care (Rev. ed.). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK233055/ Healthcare Information and Management Systems Society. (n.d.). Electronic health records . https://www.himss.org/library/ehr U.S. Code, 42 U.S.C. § 17921(5). https://www.law.cornell.edu/uscode/text/42/17921#5 International Organization for Standardization. (2011). Health informatics — Requirements for an electronic health record architecture (ISO 18308:2011). https://www.iso.org/standard/52823.html |
| web | www.cachi.org | Adapted from: California Accountable Communities for Health Initiative. (n.d.). The fundamentals . https://www.cachi.org/fundamentals |
| web | pophealthinnovationlab.org |
Adapted from: Breslau, J., Rasmussen, P. W., Qureshi, N., & Peet, E. D. (2023, November). Community care hubs: A promising model for health and social care coordination
. Office of the Assistant Secretary for Planning and Evaluation & Administration for Community Living, U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf
Population Health Innovation Lab. (2023, June 14). Backbone organization . https://pophealthinnovationlab.org/data-walk/backbone-organization/ U.S. Department of Health and Human Services. (n.d.). HHS call to action: Addressing health-related social needs in communities across the nation . https://aspe.hhs.gov/sites/default/files/documents/54c9bfde7090c3d3f02a9fd924cb3e4a/hhs-call-to-action-health-related-social-needs.pdf |
| web | doi.org | Adapted from: Galper, K., Miguel, C., LeJeune, K., Rung, J. M., Eddy, B., Kale, A., Schano, M., & Brignone, E. (2026). Design and early evaluation of a social care network's impact on health care costs. Health Affairs Scholar, 4 (3), qxag051. https://doi.org/10.1093/haschl/qxag051 |
| web | ciesandiego.org |
Kalinowski, A. G., Sorenson, P., & Johnson, B. H. (2025). Right-sizing technology for your community information exchange: A practical guide to connecting social service data systems
[Report]. 211 San Diego/CIE. https://ciesandiego.org/wp-content/uploads/2025/10/CIE-Tech-Toolkit-Digital-Final-Part-1-2025.pdf
Sorenson, P., & Bloom, G. (2021, October). Tackling data dilemmas in social care coordination: Pursuing open and equitable infrastructure across a fragmented health and social service landscape [White paper]. St. Louis Regional Data Alliance at the University of Missouri–St. Louis; Data Across Sectors for Health. https://stldata.org/wp-content/uploads/2021/10/Social-Care-Data-Whitepaper-October-2021.pdf |
| web | stldata.org |
Kalinowski, A. G., Sorenson, P., & Johnson, B. H. (2025). Right-sizing technology for your community information exchange: A practical guide to connecting social service data systems
[Report]. 211 San Diego/CIE. https://ciesandiego.org/wp-content/uploads/2025/10/CIE-Tech-Toolkit-Digital-Final-Part-1-2025.pdf
Sorenson, P., & Bloom, G. (2021, October). Tackling data dilemmas in social care coordination: Pursuing open and equitable infrastructure across a fragmented health and social service landscape [White paper]. St. Louis Regional Data Alliance at the University of Missouri–St. Louis; Data Across Sectors for Health. https://stldata.org/wp-content/uploads/2021/10/Social-Care-Data-Whitepaper-October-2021.pdf |
| web | doi.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | systemsforaction.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | med.stanford.edu |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | systemsforaction.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | systemsforaction.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | systemsforaction.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | doi.org |
Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25
(1), 2234. https://doi.org/10.1186/s12889-025-23419-3
U.S. Department of Health & Human Services. (n.d.). Social services . https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services . https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations . https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance . https://doi.org/10.1080/23303131.2026.2619153 |
| web | systemsforaction.org |
U.S. Department of Health & Human Services. (n.d.). Social services
. https://www.hhs.gov/programs/social-services/index.html
Systems for Action. (2025, May 7). Frequently asked questions . https://systemsforaction.org/frequently-asked-questions Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems |
| web | systemsforaction.org |
U.S. Department of Health & Human Services. (n.d.). Social services
. https://www.hhs.gov/programs/social-services/index.html
Systems for Action. (2025, May 7). Frequently asked questions . https://systemsforaction.org/frequently-asked-questions Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems |
| web | www.becker.com | Becker. (n.d.). Health care organizations definition . https://www.becker.com/accounting-terms/health-care-organizations |
| web | systemsforaction.org | Adapted from: Systems for Action. (2025, May 7). Frequently asked questions . https://systemsforaction.org/frequently-asked-questions |
| web | nam.edu | Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks 1 . They have long been recognized as essential factors influencing 80-90% of health outcomes . Given the breadth of their impact, assessing and addressing SDOH requires collaboration across health-related sectors — health care, social services, and public health. Models for this cross-sector collaboration are increasingly woven into health care reform, including accountable communities for health, the CMS Accountable Health Communities Model, community information exchanges (CIEs), and emerging community care hub pilots. This HL7 Implementation Guide (IG) defines how to exchange coded content across these sectors using the HL7 FHIR Standard for the following SDOH-focused care activities: use of standardized assessment instruments, assessment of social conditions, goal setting, planning and performing interventions, and reporting on outcomes. This IG addresses the need to gather reliable, evidence-based SDOH information in multiple settings, share it among stakeholders and sectors, and exchange referrals and outcomes between organizations to address specific social risks and protective factors, all with appropriate patient consent. In addition, the IG demonstrates how to share data to support secondary purposes such as population health, quality, policy, and research. |
| web | wiki.ihe.net | IHE FHIR Audit Event Query and Feed to ATNA |
| web | docs.smarthealthit.org | This IG recognizes that patients may wish to only send a portion of the MustSupport elements to another entity. However, there is currently no guidance on how to implement this as part of the FHIR R4 release. When HL7 develops standards for fine line consent, this IG will consider their applicability to the sharing of SDOH information and adopt the standards that are relevant. In the meantime, it may be possible to provide patients the ability to determine what to share by implementing SMART on FHIR applications that allow them to restrict the exchange of information that is not required to interpret the intent of a specific resource (e.g., remove address and/or telephone number from the patient resource prior to making it available to a community organization). |
| web | docs.smarthealthit.org | the SMART on FHIR Framework , |
| web | www.aap.org | The growing awareness around SDOH has contributed to efforts to address actionable social risks through the health care delivery system. Recommendations from national groups, including the American Academy of Pediatrics , American Academy of Family Physicians , Agency for Healthcare Research and Quality , National Quality Forum (NQF) , and Institute for Health Care Improvement underscore the various roles the health care system could play in helping to identify and address patients' social risks and needs. 2 |
| web | www.aafp.org | The growing awareness around SDOH has contributed to efforts to address actionable social risks through the health care delivery system. Recommendations from national groups, including the American Academy of Pediatrics , American Academy of Family Physicians , Agency for Healthcare Research and Quality , National Quality Forum (NQF) , and Institute for Health Care Improvement underscore the various roles the health care system could play in helping to identify and address patients' social risks and needs. 2 |
| web | www.qualityforum.org | The growing awareness around SDOH has contributed to efforts to address actionable social risks through the health care delivery system. Recommendations from national groups, including the American Academy of Pediatrics , American Academy of Family Physicians , Agency for Healthcare Research and Quality , National Quality Forum (NQF) , and Institute for Health Care Improvement underscore the various roles the health care system could play in helping to identify and address patients' social risks and needs. 2 |
| web | www.ihi.org | The growing awareness around SDOH has contributed to efforts to address actionable social risks through the health care delivery system. Recommendations from national groups, including the American Academy of Pediatrics , American Academy of Family Physicians , Agency for Healthcare Research and Quality , National Quality Forum (NQF) , and Institute for Health Care Improvement underscore the various roles the health care system could play in helping to identify and address patients' social risks and needs. 2 |
| web | thegravityproject.net | The Gravity Project was initiated by the Social Interventions Research and Evaluation Network (SIREN) with support from the Robert Wood Johnson Foundation . The Gravity Project mission is to create and maintain a consensus-building community to expand available SDOH Core Data for Interoperability and accelerate standards-based information exchange by using HL7 FHIR. The Gravity Project aims to standardize SDOH-related codes to facilitate the use of social determinants of health-related data in patient care, care coordination between the health and human services sectors, population health management, value-based payment, and clinical research. |
| web | chc.ucsf.edu | The Gravity Project was initiated by the Social Interventions Research and Evaluation Network (SIREN) with support from the Robert Wood Johnson Foundation . The Gravity Project mission is to create and maintain a consensus-building community to expand available SDOH Core Data for Interoperability and accelerate standards-based information exchange by using HL7 FHIR. The Gravity Project aims to standardize SDOH-related codes to facilitate the use of social determinants of health-related data in patient care, care coordination between the health and human services sectors, population health management, value-based payment, and clinical research. |
| web | www.rwjf.org | The Gravity Project was initiated by the Social Interventions Research and Evaluation Network (SIREN) with support from the Robert Wood Johnson Foundation . The Gravity Project mission is to create and maintain a consensus-building community to expand available SDOH Core Data for Interoperability and accelerate standards-based information exchange by using HL7 FHIR. The Gravity Project aims to standardize SDOH-related codes to facilitate the use of social determinants of health-related data in patient care, care coordination between the health and human services sectors, population health management, value-based payment, and clinical research. |
| web | thegravityproject.net | For more information about Gravity see the Gravity Project website or confluence site . |
| web | www.businesswire.com | Collection of personal characteristics data (e.g., Race and Ethnicity (R/E), gender identity, sexual orientation, recorded sex and gender, and personal pronouns) is important to achieving the goal of health equity. For example, the Cross-Industry Coalition Health Equity Pledge to Address Disparities , and the proposed NCQA race/ethnicity stratification approach "Episode 9", from June 22, 2021, Future of HEDIS presentation (see slides 15-25) both include a focus on the collection of Race & Ethnicity (R/E) data. |
| web | www.ncqa.org | Collection of personal characteristics data (e.g., Race and Ethnicity (R/E), gender identity, sexual orientation, recorded sex and gender, and personal pronouns) is important to achieving the goal of health equity. For example, the Cross-Industry Coalition Health Equity Pledge to Address Disparities , and the proposed NCQA race/ethnicity stratification approach "Episode 9", from June 22, 2021, Future of HEDIS presentation (see slides 15-25) both include a focus on the collection of Race & Ethnicity (R/E) data. |
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