Ask about the conditions that shape health — and act on the answers
⚠ DRAFT — state certification varies; supplements an approved program
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K
Coach Katie
Most of what keeps people healthy happens outside the clinic — in their kitchen, their home, their neighborhood. Those are the social determinants of health. A big part of CHW work is asking about them respectfully and acting on what you hear.
What SDOH are
The conditions that shape health
SDOH — Social Determinants of Health are the conditions where people live, work, learn, and age. They shape health as much as, or more than, clinical care. Whether someone has enough food, stable housing, a way to get to appointments, or a safe home can matter more to their health than any single visit.
Why CHWs screen: you're often the trusted person who first learns what someone is really up against. Naming the need is the first step to connecting them to help.
The common domains
What to ask about
🍎 Food security
Enough food; worry about running out.
🏠 Housing & utilities
Stable housing; heat, power, water.
🚌 Transportation
A reliable way to get to care and work.
💼 Employment / income
Work and enough income to get by.
🎓 Education
Schooling, literacy, learning needs.
🛡️ Personal safety
Safe at home; interpersonal violence.
🤝 Social connection
Connection vs. isolation and loneliness.
🩺 Access to care
Getting to a provider, meds, coverage.
How to ask
Screen with tools — and with respect
Validated screening tools exist so you don't have to invent the questions. Two common examples: PRAPARE and the CMS Accountable Health Communities tool. Whatever tool you use, how you ask matters as much as what you ask.
Normalize it
"We ask everyone these questions so we can connect people to help."
Ask permission
"Is it okay if I ask you a few questions about things like food and housing?"
No judgment
Keep your tone warm and matter-of-fact. Needs are common, not shameful.
Declining is okay
It's always fine for someone to skip a question or say no.
Consent & confidentiality apply to everything you collect. What someone shares is private and used only to help connect them to resources.
The most important part
A positive screen means ACT
Finding a need is only half the job. When someone screens positive, connect them to the right resource — ideally with a warm handoff (a real introduction, not just a phone number) — and close the loop by following up to see if it worked.
Screening without follow-up can do more harm than good. Asking someone to name a painful need and then doing nothing breaks trust. If you screen, be ready to act.
K
Coach Katie
Two real moments. Pick the response that is respectful, consented, and follows through with action.
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Coach Katie
Five questions. 75% to pass, then make your pledge.
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Coach Katie
Learning sticks when you commit to a next step. Pick at least two pledges you'll actually do.
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