Table 3.

Social Determinant of Health Domains and Measures Included in the ASSESS Tool and Overlap with Institute of Medicine–Recommended Domains and Measures

SDH DomainIOM-Recommended Measure/QuestionsSame in PRAPARE?ASSESS Question (If Different from IOM)Potential Actions
Alcohol use*AUDIT-C (3Q)Not includedAlready included in OCHIN EHRRefer to addiction services
How often do you have a drink containing alcohol? (never/monthly or less/2–4 times a month/2–3 times a week/≥4 times a week)How many (and what type of) drinks do you have per week? (cans of beer/glasses of wine/shots of liquor/standard drinks or equivalent; all nos.)
How many standard drinks containing alcohol do you have on a typical day? (1 or 2/3 or 4/5 or 6/7–9/≥10)
How often do you have ≥4 drinks on one occasion? (never/less than monthly/monthly/weekly/daily or almost daily)
Race/ethnicity*US Census (2Q)Which race(s) are you? Check all that apply. (American Indian or Alaskan Native/Asian/black or African American/Native Hawaiian/Pacific Islander/white/other)
Are you Hispanic or Latino? (yes/no/unreported or refused)
Already included in OCHIN EHR
What is this person's race? (white; black, African American, or Negro; American Indian or Alaska Native; Asian Indian/Chinese/Filipino/Japanese/Korean/Vietnamese/Other Asian/Native Hawaiian/Guamanian or Chamorro/Samoan/other Pacific Islander/some other race)
Is this person of Hispanic, Latino, or Spanish origin? (no/yes, Mexican, Mexican American, Chicano/yes, Puerto Rican/yes, Cuban/yes, another Hispanic, Latino, or Spanish origin)
Race: Alaskan Native/American Indian/Asian/black/Native Hawaiian/Pacific Islander/patient refused/unknown/white)
Ethnicity: Hispanic/non-Hispanic/patient refused/unknown)
Tobacco use and exposure*NHIS (2Q)Not includedAlready included in OCHIN EHRRefer to quit services
Have you smoked at least 100 cigarettes in your entire life? (yes/no/refused/don't know)Smoking status: current smoker, everyday/current smoker, some days/former smoker/heavy tobacco smoker/light tobacco smoker/never assessed/never smoker/passive smoke exposure, never smoker/smoker, current status unknown/unknown if ever smoked)
Do you now smoke cigarettes every day, some days, or not at all? (every day/some days/not at all/refused/don't know)
Smokeless tobacco: current user/former user/never used/unknown)
Depression*PHQ-2 (2Q)Not includedAlready included in OCHIN EHR; same as IOMRefer to mental health services
Over the past 2 weeks, how often have you been bothered by any of the following problems:
Little interest or pleasure in doing things (not at all/several days/more than half the days/nearly every day)
Feeling down, depressed, or hopeless (not at all/several days/more than half the days/nearly every day)
Education*What is the highest level and years of school completed? (elementary/high school/college/graduate or professional—check years completed)
What is the highest degree you earned? (high school diploma/GED/vocational certificate/associate degree [occupational, technical, or vocation program]/associate degree [academic program]/bachelor's degree/master's degree/professional/doctorate)
What is the highest level of school that you have finished? (less than high school/high school diploma or GED/more than high school/I choose not to answer this question)Adapted IOM wording to be aligned with PRAPARE and more relevant to safety net populationsIdentify patients who need more intensive care management, targeted forms of outreach, or for whom teams should consider “teach-back” methods, tailored handouts, etc.
Refer to education services (GED/skills training)
Exposure to violence: IPV*HARK (4Q)In the past year, have you been afraid of your partner or ex-partner? (yes/no)Per the recommendations of our stakeholder group, we included a more general question on violence that is aligned with Kaiser Permanente's YCLS questionnaireRefer to IPV intervention services
Have you ever been physically or emotionally hurt or threatened by a spouse/partner or someone else you know? (yes/no)
Within the past year, have you been:
  • Humiliated or emotionally abused in other ways by your partner or ex-partner?

  • Afraid of your partner or ex-partner?

  • Insult or talk down to you

  • Raped or forced to have any kind of sexual activity with your partner or ex-partner?

Do you feel physically and emotionally safe where you currently live? (yes/no)In addition, the CORC opted to include the 4-item validated HITS (Hurt-Insult-Threaten-Scream) domestic violence screening tool59,60 in the OCHIN EHR. This question will not be part of the SDH flowsheet, but positive responses will be pulled into the SDH summary and synopsis.
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner? (yes/no)
How often does your partner:
  • Physically hurt you

  • Threaten you with harm

  • Scream or curse at you

(never/rarely/sometimes/fairly often/frequently)
Physical activity*Exercise Vital Signs (2Q)Not includedSame as IOMRefer to local physical activity resources (eg, YMCA, Parks and Recreation services)
On average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?
On average, how many minutes do you engage in exercise at this level?
Social connections and social isolation*NHANES IIIHow often do you see or talk to people that you care about and feel close to? (for example, talking to friends on the phone, visiting friends or family, going to church or club meetings) (less than once a week/1 or 2 times a week/3–5 times a week/>5 times a week/I choose not to answer this question)Same as IOM; plus, per the recommendation of our stakeholders, we added an additional response to the NHANES question on weekly social contacts to encompass alternative forms of communicationRefer to community resources/support groups/group activities/volunteer services
Are you married or living together with someone in a partnership? (married or domestic partner/living with partner in committed relationship/in a serious or committed relationship, but not living together/single/separated/divorced/widowed)Provide more intensive case management
Develop an emergency action plan
In a typical week, how often do you:
  • Talk with family, friends, or neighbors by phone?

  • Get together with family, friends, or neighbors?

    (never/once a week/2 days a week/3–5 days a week/nearly every day)

In a typical week, how often do you:
  • Use email, text messaging, or Internet to communicate with family, friends, or neighbors?

How often do you:
  • Attend church or religious services

  • Attend meetings of the clubs or organizations you belong to? (never/once a year/2–3 times a year/≥4 times a year/at least once a week)

Our stakeholders also recommended including 2 more general questions on social isolation that are part of the Kaiser Permanente YCLS questionnaire
How often do you feel lonely or isolated from those around you? (never/rarely/sometimes/often/always)
Do you have someone you could call if you needed help? (yes/no)
Stress*Stress means a situation in which a person feels tense, restless, nervous, or unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days? (not at all/a little bit/somewhat/quite a bit/very much)Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you? (not at all/a little bit/somewhat/quite a bit/very much/I choose not to answer this question)We used the PRAPARE version of the question because of difficulties obtaining copyrightRefer to stress management programs
Advise closer monitoring of blood pressure, cholesterol
Financial resource strain*How hard is it for you to pay for the very basics like food, housing, heating, medical care, and medications? (not hard at all/somewhat hard/very hard)In the past year, have your or any family members you live with been unable to get any of the following when it was really needed? Check all that apply. (food/transportation/clothing/child care/utilities/medicine or medical care/rent or mortgage/phone/health insurance/other/I choose not to answer this question)Same as IOM, plus an additional follow-up question if they answered somewhat hard or very hard that is used in the Kaiser Permanente YCLSAssess food/housing insecurity
What is hard to pay for? (food/utilities food, utilities, transportation, medicine or medical care, health insurance, clothing, rent/mortgage, child care, phone)Refer to relevant social and legal services
HousingNot included in the final list of IOM-recommended domainsWhat is your housing situation today? (I have housing/I do not have housing [staying with others, in a hotel, on the street, in a shelter])/I choose not to answer this question)In the past month, have you slept outside, in a shelter, or in a place not meant for sleeping? (yes/no)
In the past month, have you had concerns about the conditions and quality of your housing? (yes/no)
In the past 12 months, how many times have you moved from one home to another?
FoodNot included in the final list of IOM-recommended domainsNot includedUSDA Household Food Security Survey Module
Which of the following describes the amount of food your household has to eat? (enough of the kinds of food we want to eat/enough but not always the kinds of food we want/sometimes not enough to eat/often not enough to eat/don't know or refused)
Please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months:
(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.
The food that (I/we) bought just didn't last, and (I/we) didn't have money to get more.
(I/we) couldn't afford to eat balanced meals.
Sexual orientation and gender identityNot included in the final list of IOM-recommended domainsNot includedThis is a required UDS data element beginning in 201664,65 and is slated for inclusion in MU-3 requirements
Sexual orientation (lesbian or gay/straight [not lesbian or gay]/bisexual/something else/I don't know/choose not to disclose/other sexual orientation [comment for other])
Gender identity (female/male/transgender female [male to female]/transgender male [female to male]/other/choose not to disclose/other identity [comment for other])
Preferred pronoun (he/him, she/her, they/them, ze/zim, decline to answer, unknown)
  • * IOM-recommended domain.

  • Already routinely collected in electronic health record (EHR).

  • Modified from item in PROMIS Item Bank version 1.0: Emotional distress, anger, Short Form 1, and AARP overall loneliness item from AARP survey about loneliness in older adults. The original PROMIS item was written in first person. Loneliness was added to reduce literacy level.

  • AUDIT-C, Alcohol Use Disorders Identification Test; GED, General Equivalency Diploma; HARK, Humiliation, Afraid, Rape, Kick; IOM, Institute of Medicine; IPV, intimate partner violence; MU-3, meaningful use level 3; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; PRAPARE, Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences; PHQ-2, 2-item Patient Health Questionnaire; SDH, social determinant of health; Q, questions; UDS, Uniform Data System; YCLS, Your Current Life Situation.