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Caring Beyond Healthcare

project logo; community buildings, hospital and home

A handful of Idaho and Washington hospitals participated in our Caring Beyond Healthcare pilot project, which developed and implemented processes to identify patients with poor social determinants of health and connect them to the community’s existing services.

The pilot wrapped up in September 2018. We're sharing the project tools to help spread this intervention across the nation.


Download the project tools:

Implementation Toolkit

Screening & Referral Form:  English   Spanish    

Patient Overview Flyer (English)


Evidence-based Screening Tools

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IHI Readmission Risk Assessment (STAAR)
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Tool (print and online versions)     Related article

(available for purchase)    Related article

Psychosocial Acuity Scale
     Related article (available for purchase)

Where does wellness happen?

Your hospital is working hard to provide top-notch medical care. But some of your patients are discharged into a world where they don’t have adequate housing, reliable transportation, or access to healthy food.

How soon will you see them again, and will they be worse for the wear?

With the transition to accountable care, these patients’ problems become yours, too.

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