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THE RESOURCE LIBRARY provides tools and resources to help essential hospitals and their partners implement community-integrated health care.

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Structural Racism

Strategic Planning

A Framework for Promoting Equity and Excellence in Healthcare

Raising the Bar & The Robert Wood Johnson Foundation (RWJF)

Raising the Bar: Healthcare’s Transforming Role is a framework for the healthcare sector to embrace and utilize all the levers, resources, and opportunities available to advance equity and excellence.

At the heart of the framework are five foundational principles for a transformed healthcare system: Mission, Equity, Community, Power, and Trust. The principles are at the heart the framework and outline commitments for healthcare to raise the bar comprehensively and holistically for equity and excellence. The principles are neither intended to be mutually exclusive nor expressed in any priority order.

Structural Racism

Strategic Planning

Bringing Light & Heat: A Health Equity Guide for Healthcare Transformation and Accountability

Siren, Health Leads, Health Begins, Human Impact Partners, JSI

This guide provides a needed framework to make health equity a core part of the organization’s mission effectively and with sustainable action.

Bringing Light & Heat: A Health Equity Guide for Healthcare Transformation and Accountability outlines a strategic process for leaders and managers of healthcare institutions to commit to, own, and advance health equity and racial justice (bringing light) and outlines key questions stakeholders can use to help hold these systems accountable for this critical work (bringing heat).

Structural Racism


Policy Brief: Wide Spread Decline in Household Income During Covid-19 Pandemic Contributes To Food Insufficiency Among Families

Institute for Women's Policy Research (Jeffrey Hayes, C. Nicole Mason, Heidi Hartmann, and Erin Weber)

The policy brief examines the pandemic's devastating impact on the economic security and well-being of families.

Using data from the U.S. Census Bureau Household Pulse Survey, this brief explores the impact of the decline of household income during the Pandemic on food sufficiency of families by race, gender, and ethnicity.

Structural Racism

Strategic Planning

Health Equity Technical Assistance

Center for Medicare & Medicaid Services

Center for Medicare & Medicaid Services offers health equity technical assistance resources aimed to help health care organizations take action against health disparities.

The CMS OMH Health Equity Technical Assistance Program offers:

  • Personalized coaching and resources to help you embed health equity into your strategic plan
  • Resources on improving care for racial and ethnic minorities, people with disabilities, individuals with limited English proficiency, sexual and gender minorities, and rural populations
  • Data collection and analysis
  • Help to develop a language access plan and to ensure effective communication with those you serve

Structural Racism

Racial Justice Toolkit

Atrium Health

The Office of Diversity & Inclusion at Atrium Health has resources to help individuals who are looking to take action to stop and prevent racial injustices.

Atrium Health’s Racial Justice Toolkit offers a curated compilation of resources for teammates and community members to advance their journey toward cultural competence.

Hospitals can share these resources for with staff to become a better friend, a better supporter and a better ally.

Structural Racism

Program Implementation

Equity in Vaccination: A Plan to Work with Communities of Color Toward COVID-19 Recovery and Beyond

CommuniVax, John Hopkins Center for Health Security & Texas State Anthropology

This plan focuses on strengthening the community’s role in equitable vaccination campaigns.

 The plan includes tools and principles to create, implement, and support vaccination campaigns that work with BIPOC communities to address inequity. 

Structural Racism

HIT Systems & Analysis

Guiding Principles: Aligning Systems with Communities to Advance Equity through Shared Measurement. 

The American Institute for Research & The Robert Wood Johnson Foundation

The American Institute for Research in partnership with The Robert Wood Johnson Foundation disseminated Guiding Principles: Aligning Systems with Communities to Advance Equity through Shared Measurement. 

The report covers guiding principles to inform measurement that effectively aligns systems’ actions with the needs and priorities of the communities those systems serve, particularly communities that historically have been harmed the most by inequities. 

Structural Racism

Strategic Planning

Strategic Goals

Christiana Care

Christiana Care outlines their strategic goals and commitment to inclusion and diversity via working towards transparency and accountability.

The Strategic Plan Goals focus on strengthening the workforce and workplace utilizing approaches to enhance recruitment, internal policies, and providing continuing educational opportunities.  

Structural Racism

HIT Systems & Analysis

Using Data to Reduce Disparities and Improve Quality

Robert Wood Johnson Foundation

This funded brief by the Robert Wood Johnson Foundation focuses on how health care providers can use data to reduce disparities and improve quality.

Essential hospitals can explore strategies that assist multi-stakeholder coalitions consisting of state Medicaid agencies, health plans, providers, and community-based organizations in organizing and interpreting data to improve health equity and reduce health care disparities. 

Structural Racism

Sustainable Funding

Leveraging Value-Based Payment Approaches to Promote Health Equity: Key Strategies for Health Care Payers

The Robert Wood Johnson Foundation, The Center for Health Care Strategies, & The  Institute for Medicaid Innovation

Essential Hospitals can develop equity-focused VBP approaches to support care delivery transformation, advancing health equity, and eliminating disparities in health care. 

The Robert Wood Johnson FoundationThe Center for Health Care Strategies, and The  Institute for Medicaid Innovation produced a report identifying strategies to guide payers in developing equity-focused VBP approaches to mitigate health disparities at the state and local level. 

Structural Racism

21-Day Anti-Racism Challenge

The Ohio State University Wexner Medical Center

The Ohio State University Wexner Medical Center adapted the 21-Day Anti-Racism Challenge.

Essential Hospitals can encourage staff to take 21 days to further their understanding of power, privilege, supremacy, systemic racism, oppression, and equity. The challenge includes suggestions for readings, podcasts, videos, observations, and ways to form and deepen community connections.  

Structural Racism

Strategic Planning

Action Plan

The Ohio State University Wexner Medical Center

The Ohio State University Wexner Medical Center created an Action Plan is comprised of four sections working to improve health equity through anti-racism efforts.

Essential Hospitals can use this Action Plan to outline institutional and individual initiatives that will enhance health equity.  

Strategic Planning

The Role of Essential Hospitals in Combating Structural Racism: An Informational Brief

America's Essential Hospitals

This new informational brief begins with a background on the impact of structural racism on patients, providers, and the community and a description of a workstream to combat structural racism.

America’s Essential Hospitals always has been guided by a vision of equity in health and health care. The Black Lives Matter movement has prompted institutions across the nation to re-examine their organizational practices and policies to better understand how institutional racism impacts their work and to make changes that promote diversity, equity, and inclusion.

Many hospital systems grapple with their role in combating the history of racism to promote equity. This new informational brief begins with a background on the impact of structural racism on patients, providers, and the community and a description of a workstream to combat structural racism for America’s Essential Hospitals and its members. It concludes with a description of twelve activities hospitals already perform to combat racism and three actions similar associations are undertaking.

Social Needs Screening

Program Implementation

Operational Guide for Essential Hospitals to Improve Complex Care

NYC Health + Hospitals and the Commonwealth Fund

NYC Health + Hospitals, with support from the Commonwealth Fund, has developed an operational guide to identify, understand, and treat patients with complex health, social, and behavioral health needs.

Essential hospitals serving complex patients can use the actionable information in this guide to replicate and implement NYC H+H’s process, including operational resources from the health system’s complex care clinic at Bellevue Hospital Center.

Strategic Planning

Checklist for Homeless Service Providers During Community Re-opening

The Center for Disease Control and Prevention (CDC)

This checklist is designed to provide homeless service providers with important considerations for service delivery as the surrounding community reopens.

The Center for Disease Control and Prevention designed this checklist and additional resources to provide homeless service providers – many of whom have remained open during the COVID-19 pandemic – with a reminder of important considerations for service delivery as the surrounding community reopens.

Housing Instability

Sustainable Funding

A Framework for COVID -19 Homelessness Response Responding to The Intersecting Crises of Homelessness and COVID-19

National Alliance to End Homelessness & Center on Budget and Policy Priorities

The purpose of this Framework is to provide guidance to communities on how to use designated funds strategically in response to the COVID-19 pandemic on homelessness.

This Framework provides guidance to communities on how to use approved funding sources for COVID-19 across a range of key public health and economic recovery strategies, to meet public health goals, to increase housing stability, and to prevent future increases in homelessness that result from an economic downturn – all with a racial justice and equity lens.

Hospital Readiness/Community Assessment

The Disproportionate Impact of COVID -19 On Black and African American Communities in The St. Louis Region

Missouri Hospital Association

Mirroring racialized COVID-19 trends in other metropolitan areas, the report focuses on disparities in the prevalence of confirmed cases among Black & African American communities in the St. Louis region.

This research brief aims to quantify COVID-19-related health disparities in the St. Louis region using ZIP code-level data on confirmed cases and demographic composition. This report concludes with recommendations for future research and action steps that enable prevention, mitigation and healing.

Multisector Partnerships

How Can Clinicians Catalyze Investments to Improve Community Health?

AMA Journal of Ethics: Robin Hacke, MBA & Alyia Gaskins, MPH

This article explores how clinicians can help keep patients healthy through supporting community investments that improves conditions that contribute to health risks, outcomes, and costs.

How Can Clinicians Catalyze Investments to Improve Community Health urge clinicians to utilize their unique position of collecting data and asking questions to support effective partnerships that address the root causes of poor health. This article discusses both how community investment can drive community health as well as how clinicians can help catalyze community investment.

Strategic Planning

Why Pioneering Health Institutions are Investing Upstream to Improve Community Health

The Center for Community Investment and The Lincoln Institute of Land Policy

This brief highlights lessons learned about the motivations that drive health institutions to invest upstream in the social determinants of health.

Why Pioneering Health Institutions are Investing Upstream to Improve Community Health analyzes what motivates hospitals to address upstream factors and next steps hospitals can take, that have emerged through research. A follow up brief contains deeper exploration into these issues.

Food Insecurity

Strategic Planning

Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions

National Quality Forum (NQF)

Drawing from diverse expert input & patient experiences, this guide includes lessons learned, innovative & promising practices, as well as solutions to common barriers to address food insecurity in communities.

Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions provides essential hospitals a range of strategies to effectively intervene and assist individuals in their communities who may experience negative health outcomes from unstable access to food. The Guide’s detailed strategies and recommendations can be tailored for organizational context, resources, and need to facilitate and enhance food insecurity interventions and ultimately improve health outcomes.

Strategic Planning

The State of Climate Resilience & Climate Mitigation Efforts at Essential Hospitals

Essential Hospitals Institute

This report assesses the resilience of essential hospitals to extreme weather events and other effects of climate change and the steps they are taking to mitigate their contribution to this problem.

The State of Climate Resilience & Climate Mitigation Efforts at Essential Hospitals: Findings and Recommendations from a Formative Evaluation report details how essential hospitals carry out infrastructure changes and work with community partners to build resiliency, as well as the challenges they face in this work.

Hospital Readiness/Community Assessment

MOVING FORWARD: A Guide for Health Professionals to Build Momentum on Climate Action

Climate for Health and ecoAmerica

The resource provides guidance and tools to reduce energy use,  build resilient clinics and health departments, and advocate for climate solutions that prioritize health and equity.

This guide is for health professionals at clinics, small healthcare practices, professional associations, and local health departments who want to lead on climate and sustainability. Essential Hospitals can play an important role as trusted messengers to engage their patients, peers, community, and policymakers on equitable climate solutions.


Social Needs Screening

COVID-19: Homelessness and Housing Resources Webinar

Essential Hospital's Institute

This webinar discusses the effects of COVID-19 on homelessness and housing.

America’s Essential Hospital staff share federal updates and provide guidance to reduce the risk for and meet the needs of homeless individuals during the COVID-19 public health emergency. Dr. Margot Kushel presents Benioff’s Homelessness and Housing Initiative and the screening tools developed to assist and aid homeless individuals during the pandemic.

Housing Instability

Recommended Strategic Approaches for COVID-19 Response for Individuals Experiencing Homelessness

Margot Kushel, MD & UCSF Benioff Homelessness and Housing Initiative

This resource is a California-specific outline of protocols and recommendations for managing homeless populations during the pandemic.

Recommended Strategic Approaches for COVID-19 Response for Individuals Experiencing Homelessness, developed in partnership with Margot Kushel, MD and the UCSF Benioff Homelessness and Housing Initiative, provide instructions to ensure the homeless population is safe and secure during the COVID-19 pandemic. The recommendations work to navigate homeless induvials to the appropriate care or housing setting based on symptoms and exposure with a focus on prevention, reducing shelter density, establishing isolation units, staffing appropriate healthcare personnel, prioritizing individual housing units, continuing outreach services, forming clear communication mechanisms, and providing paratransit.

Health Literacy

Recommendations for How to Overcome Common Barriers When Implementing Cost-of-Care Conversations

Avalere Health

This podcast (the fourth of four) delivers recommendations for overcoming barriers to implementing cost-of-care into the clinical setting.

Tune in to hear the last episode in this 4-part series that provides clinicians with recommendations for how to overcome common barriers when implementing cost-of-care (CoC) conversations. Speakers will present actionable tips that primary care clinicians can use to help address potential barriers and challenges related to implementing CoC conversations in the clinical setting.

Health Literacy

A Guide to Integrating Cost-of-Care Conversations into Workflow

Avalere Health

This podcast (third of four) from Avalere Health provides actionable pathways for clinicians to integrate cost-of-care conversations into the clinical workflow.

Tune in to hear the third episode in this 4-part series that provides clinicians with actionable approaches for integrating cost-of-care conversations into workflow.Speakers will present 3 pathways that clinicians can use to best integrate cost of care conversations into their clinical workflows.

Health Literacy

Quick Tips for Clinicians on How to Talk with Patients About the Expected Costs of Care

Avalere Health

This podcast (the second of four) focuses on why clinicians should speak with their patients about expected costs of their care and provides actionable tips for how to structure those cost-of-care conversations

The second episode in this 4-part series provides clinicians with actionable tips and a simple framework for how to structure cost-of-care (CoC) conversations with their patients. Speakers will talk with about strategies that clinicians can use to discuss costs with their patients.

Health Literacy

Why Do Cost-of-Care Conversations Matter?

Avalere Health

This Practice Brief from Avalere provides you with information and data points to create buy-in among your peers and your organization’s leadership on the importance of cost-of-care (CoC) conversations.

Health Literacy

Why Should Primary Care Clinicians Routinely Talk with Their Patients About the Expected Costs of Care?

Avalere Health

This podcast (the first of four) from Avalere Health focuses on how and why clinicians and other care team members can improve the quality and frequency of cost-of-care conversations.

Tune in to hear the first episode in a 4-part series that focuses on how clinicians and other care team members can improve the quality and frequency of cost-of-care (CoC) conversations. To kick-off this series, they will present why clinicians should speak with their patients about the expected costs of their care.

Food Insecurity

Webinar Recap: Interventions to Decrease Food Insecurity

America's Essential Hospitals

This post recaps the webinar, Interventions to Decrease Food Insecurity, and answers all remaining questions.

This post recaps a one-hour webinar, Interventions to Decrease Food Insecurity, and answers all remaining questions. This webinar was hosted by America’s Essential Hospitals and the Social Interventions Research and Evaluation Network (SIREN) to learn how health systems nationwide are exploring ways to help mitigate food insecurity among their patient populations. In addition, the post answers supplementary questions from the webinar.

Food Insecurity

Interventions to Decrease Food Insecurity

Essential Hospitals Institute (EHI) and Social Interventions Research and Evaluation Network (SIREN)

This webinar presents how health systems nationwide are exploring ways to help meet patients’ food insecurity needs.

America’s Essential Hospitals and the Social Interventions Research and Evaluation Network (SIREN) hosted a webinar to demonstrate how health systems nationwide are exploring ways to help meet patients’ food insecurity needs. Presented in this webinar are tresults from a systematic review of health care–based food insecurity interventions and a firsthand account of essential hospital’s experience delivering a food insecurity intervention. In addition,  Lee Health, in Fort Myers, Fla., presented on how they developed and evaluated Flavor Harvest @ Home, a program designed to help meet the nutrition needs of patients living in food deserts.

Workforce Capacity

Milestones for Community-Integrated Health Care at Essential Hospitals

America's Essential Hospitals

This resource helps hospitals better understand the components of community-integrated health care and outlines specific action steps to expand previous work.

The resource outlines components of community-integrated health care into actionable steps for hospitals. This report should be used as a companion resource to Outside the Hospital Walls: An Update on Essential Hospitals’ Efforts to Improve the Health of Their Communities.   

Strategic Planning

Outside the Hospital Walls: An Update on Essential Hospitals’ Efforts to Improve the Health of Their Communities

America's Essential Hospitals

This resource expands on the Essential Hospitals Institute's foundational research about essential hospitals’ work to improve Social Determinants of Health.

This report is based on results from a survey fielded to hospital leaders and interviews with hospital representatives, funded by the Robert Wood Johnson Foundation. The resource provides an update on essential hospitals addressing patient social needs, building capacity, forming and maintaining partnerships, advancing community health, driving community-integrated health care, and overcoming challenges. This report should be used as a companion resource to Milestones for Community-Integrated Health Care at Essential Hospitals.



Hospital Readiness/Community Assessment

Health Equity Report Card

Salud America!

This website creates reports to show how each county is doing on a variety of health-related conditions compared to the rest of the state and nation.

The data in each report compares county statistics in housing, transportation, poverty, healthcare, mental health, environmental issues, and access to healthy food and active spaces.  Essential Hospitals can use this website to understand their patient population and identify their community needs in regards to socioeconomic and health issues with a focus on equity.

Housing Instability

Preserving, Protecting, & Expanding Affordable Housing A Policy Toolkit for Public Health

Change Lab Solutions

This toolkit provides information on housing market trends and research on the links between rising housing costs and poor health outcomes.

Preserving, Protecting, & Expanding Affordable Housing: A Policy Toolkit for Public Health identifies strategies across six policy areas to help ensure that households of all incomes have housing options in the areas where they want to live. Essential hospitals can advocate enabling affordable housing in their communities with these outlined policies.

Multisector Partnerships

Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health

United Hospital Fund (UHF) and Population Health Improvement Program (PHIP)

This report is an initial framework for primary care providers to establish social needs screening and referral programs in concert with human services partners.

The report provides a framework for better integrating primary care and social services in urban communities. It delivers guidance on a variety of issues such as choosing a screening tool, developing a realistic workflow, identifying appropriate CBO partners, and building relationships. In addition, this report explores how these referral processes work in the “real world.”

HIT Systems & Analysis

Community Resource Referral Platforms: A Guide for Health Care Organizations

SIREN- Social Interventions Research & Evaluation Network

This guide was developed to help essential hospitals understand the landscape of community resource referral platforms and learn from early adopters’ experiences using them.

Community Resource Referral Platforms: A Guide for Health Care Organization is based on interviews with representatives from 39 organizations. This guide explores and compares community resource referral platforms and provides lessons learned and recommendations for organizations. Platforms explored: Aunt Bertha, Charity Tracker, Cross Tx, Healthify, NowPow, One Degree, Pieces Iris, TAVConnect (TAVHealth), Unite Us.


Confronting Transportation Barriers to Improve Health

America's Essential Hospitals

Essential hospitals and health systems have a vested interest in and are uniquely positioned to drive population health improvements, particularly related to transportation barriers.

In this brief, America’s Essential Hospitals examines state policies,  literature, and examples of programs at member hospitals aimed at preventing and reducing barriers to transportation. Support for this brief was provided by the Robert Wood Johnson Foundation.


  • Access to transportation is a social determinant of health that influences health outcomes, affects access to health care, and intersects with other social determinants.
  • Transportation barriers disproportionately affect low-income, vulnerable communities, contributing to health disparities.
  • Essential hospitals are implementing efforts to reduce transportation barriers for their patients and communities.
  • States offer eligible patients reliable transportation to and from health care appointments as a mandatory Medicaid benefit and have invested in transportation infrastructure to promote access to care and healthier lifestyles.
  • Leveraging state resources to provide transportation for eligible patients can enable essential hospitals to target resources upstream, reducing transportation barriers at the community level.

Workforce Capacity

Population Health Leadership at Essential Hospitals— A Toolkit for Hiring and Evaluating Population Health Executives

America's Essential Hospitals & The Kresge Foundation

This toolkit details a core skill set and hiring considerations for population health executives and provides a template job description and skill assessment worksheets.

Essential hospitals can use this toolkit, developed with support from the Kresge Foundation, to build the workforce and leadership they need to cope with social, economic, and environmental factors while having the greatest impact on health in the neighborhoods they serve.

Strategic Planning

Community Benefit Insight

RWJF, RTI International, & Public Health Institute

Community benefit requirements play a large role in population health initiatives. With this resource, essential hospitals can access information about how other hospitals are leveraging these requirements.

Community Benefit Insight offers an online database of tax-exempt hospital community benefit spending information. Users can search for a specific hospital or browse by state. In addition, the website includes a compendium of resources for understanding and utilizing community benefit requirements, as well as additional tools from external organizations.


The Trauma, Health & Learning Connection in Schools

Trust for America's Health & Healthy Schools Campaign

In this webinar recording, learn about the role schools play in addressing childhood trauma, and how this ultimately influences health.

Listeners will hear speakers discuss examples of successful practices on the state-level within California and explain why trauma-informed schools matter for health equity, learning and achievement. This webinar also provides an overview of the role that Medicaid plays in school-based services reimbursement. Essential hospitals can refer to this webinar as they develop and implement partnerships, programs, and evaluations within the education sector.

Sustainable Funding

ROI Calculator for Partnerships to Address the Social Determinants of Health

The Commonwealth Fund

This online tool assists medical providers and their community-based partners in creating mutually advantageous financial arrangements when collaboratively addressing the social determinants of health.

Essential hospitals can use this tool, with their partners, to account for specific costs and needs of their patient populations, and calculate financial returns for population health interventions. Those who use this tool are walked through a straightforward, user-friendly process which provides guidance on the type of data that will be needed to calculate returns. What’s more, after completing the process, a summary is provided of the calculation as it pertains to all partners.

This tool is currently in beta stages and will continue to be updated.

Food Insecurity

Program Implementation

Delivering Community Benefit: Healthy Food Playbook

Health Care Without Harm

This online playbook comprises a suite of resources to support hospitals and community partners in developing community health interventions to address food insecurity.

Specifically, users can access a number of online tools under three main categories: community health needs assessment; implementation strategy; and evaluating, reporting, and communicating results. Essential hospitals will find the Playbook exceptionally helpful in learning more about the different types of models used to address food insecurity, as well as accessing case studies and research documents.

Multisector Partnerships

Partnership Assessment Tool

Nonprofit Finance Fund

This resource is designed to assist health care providers and their community-based organization partners maintain a productive, mutually beneficial partnership.

The Partnership Assessment Tool for Health (PATH) is an interactive document to be used in a conversation between partners. Specifically, PATH walks partners through three steps, including a Partnership Check-Up and Partner Discussion Guide. Essential hospitals will find this tool useful in facilitating open and honest dialogue around strengths, gaps, challenges, and opportunities with their community-based partners.

Additional population health tools can be found on the Nonprofit Finance Fund website, including more information about the PATH initiative from the Robert Wood Johnson Foundation, the Partnership for Healthy Outcomes, the Nonprofit Finance Fund, the Center for Health Care Strategies, and the Alliance for Strong Families and Communities.

Housing Instability

Hospital Readiness/Community Assessment

The Eviction Lab

Princeton University

From Princeton University, this online database provides statistics on evictions - a strong indicator of housing instability - at the community level.

Essential hospitals can use this free tool to better understand eviction rates in their communities, and produce custom maps, charts, and reports. In addition, the Eviction Lab website hosts additional resources, including educational videos and links to other related organizations.

Interpersonal Violence

Program Implementation

Cure Violence Health Model

Cure Violence

The Cure Violence Health Model has been implemented in cities across the U.S. and is proven to help reduce community violence. Now a full implementation guide is available online to help spread the model.

Essential hospitals can utilize this new implementation guide to implement the Cure Violence Health Model at their hospitals and in their communities. The resources available include monthly webinars, reference documents, and videos. In addition, the Cure Violence organization offers additional resources for understanding violence, the impact of violence on health, and evidence behind the health model.

Interpersonal Violence

Essential Hospitals: Community Anchors in Violence Prevention

America's Essential Hospitals

Essential hospitals and health systems have a vested interest in and are uniquely positioned to drive population health improvements, particularly related to interpersonal violence.

In this brief, America’s Essential Hospitals examines literature and examples of programs at member hospitals aimed at preventing and reducing interpersonal violence. Support for this brief was provided by the Robert Wood Johnson Foundation.


  • Violence is a social determinant of health that affects health risks and outcomes for individuals, communities, and the hospitals who serve them.
  • Interpersonal violence disproportionately effects vulnerable populations, youth, and those in metropolitan areas.
  • Essential hospitals use population health approaches to combat interpersonal violence in the communities they serve.

Social Needs Screening

Hospital Readiness/Community Assessment

The Accountable Health Communities (AHC) Health-Related Social Needs

Center for Medicare and Medicaid Innovation

The Accountable Health Communities Health-Related Social Needs Screening Tool aids in identifying and addressing unmet health-related social needs of patients within a clinical setting.

Essential hospitals can use this 10-question screening tool to identify patient’s unmet health-related social needs within housing instability, food insecurity, transportation, utility, and interpersonal safety. Using the screening tool can help providers make appropriate referrals to hospital and/or community based services that can best address these needs.


Transportation and Health Tool


The Transportation and Health Tool (THT) provides access to data and strategies that examine the health impacts of transportation systems.

THT was created in conjunction with the U.S. Department of Transportation (USDOT), the Centers for Disease Control (CDC), and the American Public Health Association (APHA) to look at specific indicators from each U.S. state addressing how transportation can affect air quality, safety, active transportation, and connectivity to destinations. THT provides information to assist in understanding the relationship between transportation and health as well as addressing tactics to improve public health through transportation planning and policy. Essential hospitals can use the tool to examine transportation-related health indicators by state, metropolitan and urban areas, and to identify transportation strategies to help address those health concerns.

Check out how five unique organizations and hospitals used the Transportation and Health Tool to improve community health on APHA’s website.

Health Behaviors

Hospital Readiness/Community Assessment


de Beaumont Foundation

CityHealth provides an interactive way to view and compare population health related policies in different cities across the United States.

The website can be sorted by city or by policy, with 40 major US cities to choose from. Users can view policies that are in place for topics such as healthy food procurement, tobacco regulation, and zoning for affordable housing. Bronze, silver, and gold medals are assigned to each city, and specific details about each healthy policy are provided. Essential hospitals can utilize this tool to view how their city ranks for a variety of population health related policies, and view recommendations for improving these policy areas.

Health Literacy

Quick Guide to Health Literacy

US Department of Health and Human Services

This guide provides the information necessary for health care providers to better understand health literacy and become clear communicators with patients.

The Quick Guide to Health Literacy outlines a streamlined approach to making health information appropriate for the user and easy to use. It also provides tips for ensuring that health providers are communicating clearly and effectively. Essential hospitals can utilize the examples of easy-to-read flyers, the checklist for improving the usability of health information, and the list of additional resources provided.

Family & Social Support

Hospital Readiness/Community Assessment

The Circle of Support Approach Organizational Self- Assessment

Substance Abuse and Mental Health Services Adminstration

This self-assessment from SAMHSA allows hospitals to evaluate the current policies, practices, and systems at their organization that encourage patients to build and maintain their social network.

Essential hospitals can use this self-assessment to evaluate how well their organization addresses patients’ social network needs. The assessment includes questions about policies, workforce development, procedures and practices, resources and services, and documentation. By ranking their organization on a scale of 0 to 4 for each question, hospitals can evaluate how they are currently encouraging family and social supports, and what additional improvements can be made. Improving patient’s social support systems and resources can lead to better personal health management.

Employment & Income

Strategic Planning

The Future of Health is Local: A Field Guide for Health Sector Leadership

Business Alliance for Local Living Economies (BALLE)

This strategic guide from BALLE is designed to help health care institutions to align the non-clinical assets of their organization and improve local economy.

Essential hospitals can use this guide for ideas and practical strategies for creating local partnerships, particularly with local businesses and entrepreneurs. Throughout the guide, “localism strategies” are linked with six social determinants of health, with specific examples of how to coordinate external partnerships and maximize community benefit. Additionally, several case studies included in the guide provide tactical examples of how hospitals and health systems are employing their non-clinical assets to advance the health of their community.

Sustainable Funding

Financing Regional Health Transformation: A Primer for Changemakers

ReThink Health

ReThink Health’s Financing Primer takes a broader look at health care financing, including the challenges and opportunities in today’s payment environment for population health.

Essential hospitals can walk through the six steps of the Primer to hear commentary from health care thought leaders, watch informational videos, and access resources for sustainable financing mechanisms. The online tool also encourages collaboration in this area and provides examples of community-wide financing arrangements.

Food Insecurity

Food Insecurity, Health Equity, and Essential Hospitals

America's Essential Hospitals

Food insecurity is a serious health problem for people and communities nationwide, with profound clinical consequences and a deep connection to sociodemographic factors that affect health.

This brief summarizes the challenges that food-insecure patients face and measures hospitals can take at the patient, system, and community levels to help create food security.


  • Food insecurity is significantly associated with a number of physical and behavioral health outcomes.
  • Poor health and food insecurity often exacerbate each other, perpetuating a cycle of chronic illness that contributes to high health care costs and utilization.
  • Food insecurity disproportionately affects vulnerable populations and is driven by social, economic, and environmental factors.
  • Essential hospitals have a unique opportunity and responsibility to address food insecurity to improve  patient and population health.
  • Hospitals can address food insecurity through screening, on-campus resources, community partnerships and engagement, and referral to nutrition assistance programs.


The Intersection of Health and Transportation

America's Essential Hospitals

To what extent are transportation services related to the health and wellness of individuals? What role do essential hospitals play in transportation?

This webinar offered a discussion on how transportation services and health and wellness may be related and provides a glimpse into how two essential hospitals are addressing community transportation needs.


Hospital Readiness/Community Assessment

The Children’s Health and Education Mapping Tool

School-Based Health Alliance

This tool allows users to visualize child and adolescent health at the community level, as well as explore characteristics of school-based health centers and public schools, for data-driven decision making.

Essential hospitals can use this resource to create maps which highlight areas of need related to education and health. In addition, features in the tool allow users to map health care access points, public schools, and school-based health centers to identify potential partners. The mapping tool is a free resource offered by the School-Based Health Alliance, which also hosts several other resources for health and education on their website.

Workforce Capacity

Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings

Sinai Urban Health Institute

Community health workers (CHW) can play a vital role in patient and community engagement, and are increasingly being integrated into hospitals and health systems as part of population health improvement.

This report from Sinai Urban Health Institute – an affiliate of America’s Essential Hospitals’ member, Sinai Health System – aims to provide a comprehensive look at the CHW model and how to successfully incorporate CHW into the hospital and health system workforce. The evidence-based guidelines are presented through five sections, from hiring to evaluation, which cover all aspects of CHW integration. Essential hospitals can use these guidelines as they consider adopting the CHW model or revising current programs.

Multisector Partnerships

A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health

Health Research & Educational Trust

This playbook provides a step-by-step guide for engaging partners, collaboratively implementing population health strategies, and sustaining successful partnerships.

Essential hospitals can use this playbook to learn more about a “culture of health” and the value of partnerships, and as a workbook for population health collaboration. The document offers graphics, worksheets, templates, and more to walk users through every step of building and fostering partnerships.

Community Infrastructure

Program Implementation

Building Healthy Places Toolkit

Urban Land Institute

This toolkit offers strategies for enhancing health through changes to the built environment, specifically related to physical activity, food and water, and the environment.

Although originally intended for community development audiences, essential hospitals can use this toolkit to develop population health initiatives with urban planning partners. The toolkit provides 21 evidence-based recommendations for community health improvements through an interactive website and formal report. In addition, several case studies are featured on the site for examples of the recommendations in action.

Hospital Readiness/Community Assessment

Community Health Assessment Toolkit

Association for Community Health Improvement

This toolkit provides a step-by-step guide across nine elements of community health assessment.

Essential hospitals can use this toolkit to better engage their communities and assess community needs. As a generic guide, it provides a foundation for IRS regulated community health needs assessments (CHNA), but can be used by all hospitals and their partners. Each step is a quick and easy read which covers key components and strategies. Additionally, case examples are provided for some steps, as well as compendium of resources for the overall process.

Hospital Readiness/Community Assessment

Vital Signs: Core Metrics for Health and Health Care Progress

National Academy of Medicine

Vital Signs comprises a standardized set of 15 core measures aimed at yielding the clearest understanding of the health and well-being of Americans.

The measures are broken down into four categories – healthy people, high-quality care, affordable care, and engaged people – and can be applied at the national, state, local, and institutional level. Essential hospitals can use these measures to better understand the needs of their community and progress in population health improvement. The National Academy of Medicine (formerly the Institute of Medicine) offers several resources for using Vital Signs, including reports, infographics, videos, and webinars.

Hospital Readiness/Community Assessment

Community Commons

Institute for People, Place and Possibility/ Center for Applied Research and Environmental Systems/ Community Initiatives

Community Commons is an online resource center for analyzing and visualizing community data.

Essential hospitals can access the free tools on the site to develop maps and reports for their communities using social, economic, education, health, and environmental data. Such data visualization can provide context to community needs in a way that is easy to understand. What’s more, Community Commons encourages collaborative community initiatives and serves as a space to learn from and connect with potential partners.

Community Infrastructure

Program Implementation

Improving Community Infrastructure: Lessons from Detroit

America's Essential Hospitals

In this webinar, Henry Ford Health System shared how it's working to improve Detroit’s infrastructure through community revitalization programs.

Tom Habitz, an Urban Planning Specialist with Henry Ford Health System, discussed the diverse community development projects underway, how the health system engages its local community, and lessons learned from collaborating with local partners. In addition, Mr. Habitz provided an overview of Henry Ford Health System’s other initiatives to address the social determinants of health.

Health Behaviors

Program Implementation

Park Rx

National Recreation and Park Association/ Institute at the Golden Gate/ National Park Service

Park Prescriptions (Rx) are programs designed in collaboration among public land agencies, health care providers, and community partners to encourage people to utilize parks, trails, and open space.

The ParkRx website hosts a number of resources for developing park prescription programs. Specifically, essential hospitals can use the program toolkit for clinical providers which includes worksheets, videos, and other resources. Additional toolkits are offered for program partners such as public health, community organizations, and park departments. Essential hospitals can also access communication materials, educational webinars and reports, and numerous success stories.

Food Insecurity

Program Implementation

Addressing Food Insecurity: A Toolkit for Pediatricians


This toolkit from the Food Research & Action Center (FRAC) and American Academy of Pediatrics (AAP) aims to help providers screen for food insecurity and connect families to food and nutrition resources.

Essential hospitals can use the toolkit as a step-by-step guide for incorporating food insecurity screening and intervention strategies into institutional workflow. Specifically, the toolkit provides helpful steps for educating staff, screening using The Hunger Vital Sign™ (a validated, AAP-recommended screening tool), and responding to patients’ needs.

Interpersonal Violence

Program Implementation

Interpersonal Violence and Hospital-Based Intervention

America’s Essential Hospitals

This webinar highlighted the hospital role in community violence prevention and intervention, the value of hospital-based violence intervention programs, and resources for implementing such initiatives.

Founding members of the National Network of Hospital-Based Violence Intervention Programs (NNHVIP) – Youth ALIVE! and Boston Medical Center – discussed the core components of hospital-based violence intervention programs and provided examples from their own communities.

Access additional resources for hospital-based violence intervention programs at

Social Needs Screening

Hospital Readiness/Community Assessment

SIREN Evidence Library


The Social Intervention Research & Evaluation Network’s (SIREN) Evidence Library provides research articles, issues briefs, reports, and commentaries about addressing social needs in the clinical care setting.

Essential hospitals can use this research library to explore the evidence behind population health interventions, which can support community assessment, program design, and communicating return on investment. SIREN also provides resources for other population health strategies, such as screening for social determinants, metrics and evaluation, and grant writing.

Multisector Partnerships

Practical Playbook

Practical Playbook

The Practical Playbook is a printed resource with an associated website aimed at helping public health and primary care collaborate around population health.

The paperback playbook hosts several expert strategies around public health-health care collaboration that may be beneficial to essential hospitals seeking to form community partnerships. In addition, the Practical Playbook website offers further resources and tools for successful partnerships, data utilization, sustainable funding, and other population health topics.

Hospital Readiness/Community Assessment

AGLH Hospital/Health System Self-Assessment Tool

Governance Institute

From Alignment of Governance & Leadership in Healthcare (AGLH), this self-assessment tool can help hospitals/health systems prepare for population health.

The tool includes a seven-part, straightforward assessment in the areas of: board engagement, data systems and management, financing/payment models, delivery system re-design, community benefit/community health, intersectoral collaboration, and policy development. Essential hospitals may benefit from completing this self-assessment as a first step to implementing a population health approach.

Hospital Readiness/Community Assessment

County Health Rankings

University of Wisconsin Population Health Institute/RWJF

County Health Rankings is an online resource center focused on providing reliable data and resources about health and social determinants to inform communities.

The site provides the Health Rankings database for local-level data, as well as numerous resources for implementing population health policies or programs such as the Roadmaps to Health Action Center and What Works for Health compendium. The data provided by County Health Rankings can serve as a valuable benchmark for essential hospitals as they assess community needs.

Multisector Partnerships

Mobilizing for Action through Planning and Partnerships (MAPP)


MAPP is a community-driven strategic planning tool which can help communities identify and address social determinants of health.

This online resource hosts six modules around key public health infrastructure phases, each with several phase-specific tools. In addition, users can access the MAPP Network to connect with local public health departments and other community partners. While designed primarily for public health professionals, MAPP is not an agency-specific tool and can benefit essential hospitals as they work with local organizations around community health assessment and improvement.

Hospital Readiness/Community Assessment

Population Health 101

America's Essential Hospitals

In this educational webinar, Essential Hospitals Institute staff provided an overview of population health and shared how essential hospitals are working to improve the health of their communities.

Attendees learned how social forces affect health and how essential hospitals can partner with local organizations to positively influence these forces. Institute staff shared how America’s Essential Hospitals’ resources and programs can support members in developing, implementing, and growing population health initiatives.

Strategic Planning

Hospitals Aligned for Healthy Communities

Democracy Collaborative

The Hospitals Aligned for Healthy Communities toolkit series, developed by the Democracy Collaborative, offers numerous resources for leveraging the anchor mission for population health.

As essential hospitals often assume the role of anchor institution in their communities, this is a valuable resource for strategic planning. The site features three toolkits specific to workforce, purchasing, and investment. Each toolkit offers case studies, videos, graphics, and step-by-step guides for key strategies.

Learn more in America’s Essential Hospitals’ webinar – Hospitals as Anchor Institutions for Population Health.

Utility Needs

Program Implementation

Green & Healthy Homes Initiative


The Green & Healthy Homes Initiative is a national organization dedicated to promoting safe and healthy housing.

Their site offers a number of tools that can benefit essential hospitals working in this area. These include: eight standards for healthy homes, home health risk assessment quiz, information and strategies around common household health risks, and educational and technical assistance resources.

HIT Systems & Analysis


National Association of Community Health Centers

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a tool for health care providers to collect patient data related to social determinants of health.

Essential hospitals can access the PRAPARE assessment tool, as well as the PRAPARE Implementation and Action Toolkit. PRAPARE also includes electronic health record templates for data integration and guides for ICD-10 codes related to social determinants. While PRAPARE was originally developed for community health centers, it has successfully been implemented by hospitals and larger health systems.

Learn more in America’s Essential Hospitals’ webinar – PRAPARE: Using Health IT for Population Health.

Community Infrastructure

Multisector Partnerships

Build Healthy Places Network

Build Healthy Places Network

The Build Healthy Places Network supports collaboration between health care and community development sectors to promote wellness in low-income communities.

Essential hospitals can access the BHPN website for a number of resources for population health, including: a Jargon Buster for “learning the language” of each sector, MeasureUp for program evaluation, the Partner Finder directory, live online discussion events, and multiple case studies of successful collaboration in communities across the country. In addition, Build Health Places Network produces a newsletter (The Pulse) and e-magazine (Crosswalk) to share stories and updates from the field.

Program Implementation

Health Impact in 5 Years (Hi-5)


Health Impact in 5 Years, developed by the CDC, offers resources for 14 community-based interventions to improve health.

These interventions are categorized by “Changing the Context,” as to make healthy options easy or the default choice, and “Addressing Social Determinants.” Essential hospitals and their community partners can reference these interventions when developing population health initiatives. Each of the 14 interventions is evidence-based and has a proven track record to impact health.