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Complete an SDOH assessment

Screen a member for social determinants of health — housing, food, transportation, utilities, and personal safety — and record any identified needs on their record.

Before you start​

  • You need a role that can create SDOH assessments (Nurse Care Manager, Social Worker, Behavioral Health Clinician, or Care Coordinator).
  • In the left menu, go to Members → SDOH Assessment Queue.
  • You can also start directly from a member's workspace: open the member and click SDOH Assessment under Role Actions.

Steps​

  1. On the assessment queue page, click New Assessment.
  2. You're taken to member search — find and select the member you're assessing. The SDOH Assessment form opens for that member.
  3. For each of the five screening domains — Housing instability, Food insecurity, Transportation access, Utility shutoff risk, and Personal safety / IPV — choose one answer:
    • Yes — need identified
    • No — no concern
    • Decline / unknown
  4. When you mark a domain Yes, an optional Note field appears — add context about the need (for example, who will follow up).
  5. Add an Overall summary at the bottom if helpful (for example, "Patient reports food + transport needs; SW will follow up with referrals").
  6. Click Save Assessment. You return to the member's Face-Sheet, and any identified needs are flagged on the record so the care team can act on them.

Tips / Troubleshooting​

  • Domains you leave unanswered are recorded as not asked — answer every domain you actually screened.
  • Identified needs feed the member's care gaps and can be addressed with a community referral (see Role Actions → Refer to Community in the member workspace).