MSPPS Partners Develop and Implement Social Determinant of Health Screening Tool MSPPS Partners Develop and Implement Social Determinant of Health Screening Tool

PPS News

MSPPS Partners Develop Social Determinant of Health Screening Tool

Mount Sinai PPS (MSPPS) has developed a social determinant of health screening (SDH) tool in collaboration with care management agencies, social work departments, federally qualified health centers, and a home care agency partnering with the PPS. The tool addresses several needs – including food/nutrition, housing, income, literacy, transportation, safety, and health care.


The SDH tool was implemented with a pilot group of MSPPS partners over the past year. At the end of the pilot, partners unanimously agreed on the importance of SDH screening to provide better services and care for patients. Pilot partners are considering how to incorporate SDH tools in their workflows. Some partners discovered that SDH conversations were likely to occur with various members of the care team and not just the social worker or behavioral health provider.

These initial findings were shared at the New York State Third Annual Learning Symposium by Dr. Theresa Soriano, co-chair of the Mount Sinai PPS Clinical Quality Committee. Dr. Soriano is Senior Vice President of Care Transitions & Population Health at Mount Sinai St. Luke’s Hospital.

Montefiore Health System and Mount Sinai St. Luke’s also presented at the symposium session and reiterated the importance of SDH screenings. Their presentations highlighted that financial stress, housing insecurity, behavioral health concerns, and access to primary care services were among some of the top social determinants impacting patients.

As a next step, MSPPS will continue to gather feedback from the pilot group to standardize and expand the screening tool across the network. Additionally, MSPPS is exploring strategies to strengthen the relationship between community and clinical services. Stay tuned for more information.

A full download is available to MSPPS partners by clicking here and logging in with your Community Gateway information.

Read about Community Resource Guide, our Community Gateway application, to help providers identify community resources for patients.

MSPPS SDH Screening Tool

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