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Social Determinants of Health

In 2018, we launched a Social Determinant of Health screening and referral tool. Our community navigators and healthcare providers screen clients for their social needs, help prioritize what matters most and then close the loop on immediate referrals to local social service providers. Read more about the tool here.

How partners are using the screening tool

PPS partners use the screening tool to:

  • Identify any barriers patients have
  • Make immediate linkages to resources for urgent needs
  • Facilitate linkage for social factors to CBOs
  • Connect patients to insurance who do not have one
  • Connect patients to PCP who do not have one
  • Schedule PCP appointments for patients who have not been to their medical doctor in last 12 months
  • Close the referral loop within 4 weeks

SDOH script to introduce screening tool

“During this meeting I want to make sure that we address what is important to you to get help with as well as other areas of your lifestyle that it might be useful for you and me to address. Sometimes there are things going on in our lives and we do not realize they can affect our _________ (recovery, health, well- being, ability to care for our needs etc.) To do that I will introduce a variety of topics to you. You may find some of them do not have an impact on you and those we do not need to talk about. I want to introduce all the topics to make sure we provide the best care planning for you.”

Download the script here.

Partners currently using the tool

  • Camelot Counseling
  • Community Health Action of Staten Island
  • Community Health Center of Richmond
  • EG Healthcare
  • El Centro del Inmigrante
  • Island Voice
  • Jewish Community Center of Staten Island
  • Make the Road New York
  • Metro Community Health Centers
  • Project Hospitality
  • Richmond University Medical Center
  • Silver Lake Support Services
  • South Beach Psychiatric Center
  • Staten Island Mental Health Society
  • Staten Island University Hospital
  • Venture House
  • Victory Internal Medicine
  • YMCA



Success Stories


Tool & Program FAQ

Resource Guide

Resource FAQ

Social Determinant of Health Resource Webinars

Staten Island PPS is hosting a series of webinars to highlight high-level resources in each Social Determinant of Health resource category and hopes to spark the conversation on much needed structural, system and policy changes needed to address the root cause of these social issues. You can register and learn more here. Below are the recordings of each webinar.

Food Insecurity and Resources Webinar

Housing Insecurity and Resources Webinar

Literacy and Safety Resources Webinar

Clothing, Socialization and Child Services Webinar