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Quality Improvement

Use Tools or Approaches to Screen For and/or Assess Complexity Related to the Social Determinants of Health, Particularly Income, Housing, and Food Stability

This practice is intended to build on the guidance provided by the Ministry of Health and Long-Term Care and the coordinated care management innovative practices previously endorsed by the Clinical Reference Group, which encourage Health Links to "identify patients" for coordinated care management using both “clinical and data-driven case-finding approaches.” This practice places an emphasis on using standardized tools and/or clinical assessment methods to screen for/assess issues relating to social determinants of health in order to identify patients who may benefit from coordinated care management when indicated. It may also be used to complete further assessment and planning during the next step in the coordinated care management process: interview, gather information, and initiate care plan.

Innovative Practices

Using the Innovative Practices Evaluation Framework, Health Quality Ontario’s Health Links Clinical Reference Group has endorsed the following innovative practice or practices. Please click on the link(s) below to discover the steps for implementation, and to access resources that Health Links have used to successfully implement these practices. 

Innovative Practice

Innovative Practice Assessment*

Clinical Reference Group Endorsement for Spread

Use tools or approaches to screen for and/or assess complexity related to the social determinants of health, particularly income, housing, and food stability


Provincial spread with reassessment using the Innovative Practices Evaluation Framework* in 1 year (April 2018)

Document Links:

*For more information about the Innovative Practices Evaluation Framework assessments, please go to the following link:

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