The following sections contain information on screening tools, referral forms, and community resources in LA County.
Key Terms and Points
- SDOH: The conditions in the environments where people are born, learn, work, and age that affect a wide range of health and quality of life outcomes
- Z codes: A set of ICD-10-CM* diagnosis codes used to document SDOH data
- Anyone on the care team, including community health workers and patient navigators, can input Z codes on an EHR like Epic (CMS, Using Z Codes)
*ICD-10-CM is International Classification of Diseases, Tenth Revision, Clinical Modification
Accountable Health Communities Health-Related Social Needs Screening Tool (AHC)
- Core questions: 1-10
- AHC: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE)
- Core questions: 1-17
- PRAPARE: https://prapare.org/wp-content/uploads/2023/01/PRAPARE-English.pdf
Community Link: Yelp-like platform for community resources (financial assistance, food pantries, and other free or reduced-cost services) https://communitylink.lacare.org/
L.A. Care & Blue Shield Promise Community Resource Centers (CRCs): Free health and wellness classes, enrollment support for Medi-Cal and other health coverage programs, and more services https://www.communityresourcecenterla.org/services
L.A. Care Meals as Medicine: Healthy home-delivered meals tailored to a person’s health needs (for eligible members and provider referral needed) https://www.lacare.org/providers/community-supports/meals
L.A. Care Meals as Medicine Referral Form https://www.lacare.org/sites/default/files/pl1785_meals_sar_form_202401.pdf
CalFresh: Monthly food benefits for individuals and families with low-income https://www.getcalfresh.org/
LA Regional Food Bank: They distribute food and other essentials to children, seniors, families and other individuals in need https://www.lafoodbank.org
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): Food benefits and nutrition information for growing families https://myfamily.wic.ca.gov/Home/HowCanIGetWIC#HowCanIGetWIC
L.A. Care Doula Benefit for Expectant Mothers: Health education, advocacy, and physical, emotional and non-medical support for pregnant and postpartum persons (for eligible members, provider recommendation form may be needed) https://www.lacare.org/providers/news/thepulse/doula-support-expectant-mothers
Doula Recommendation Form: (Provider Form) https://www.lacare.org/sites/default/files/files/la4996_doula_form_202302.pdf
L.A. Care Healthy Mom Program (HMP): Provides support for new moms to get the postpartum care that they need https://www.lacare.org/healthy-living/library/healthy-mom
Doula Recommendation Form: (Provider Form) https://www.lacare.org/sites/default/files/files/la4996_doula_form_202302.pdf
CinnaMoms: Hosts virtual support circles to support women who breastfeed https://www.cinnamoms.org/resources
L.A. Care Transportation Services: Both emergency and non-emergency transportation benefits (for L.A. Care members) https://www.lacare.org/members/transportation
Low Income Fare is Easy (LIFE) Program: Offers free rides and discounted Metro and transit agency fares for qualifying LA County residents https://www.metro.net/riding/fares/life/
Metro GoPass: All students at participating K-12 and Community Colleges can ride Metro buses and trains for free with GoPass after contacting their school https://lacmta.github.io/gopass-lookup
L.A. Care Enhanced Care Management (ECM): Services for Medi-Cal members with complex health and/or social needs
- ECM Eligibility https://www.lacare.org/providers/ecm/eligibility
- ECM Referral Process https://www.lacare.org/sites/default/files/ECMReferralSubmissionProcess.pdf
- ECM Referral Form https://www.lacare.org/sites/default/files/pl1196-1198_la_mcp_ecm_referral_form_202112.pdf
L.A. Care Homeless and Housing Support Services Program (HHSS): Housing navigation and tenancy services (provider referral needed) https://www.lacare.org/providers/community-supports/hhss
Provider HHSS Referral Process https://www.lacare.org/sites/default/files/la3764_hhss_reference_guide_202203_0.pdf
Provider HHSS Referral Form https://www.lacare.org/sites/default/files/la3695_hhhs_form_202205_1.pdf
Highly Recommended Community Link Resources in the Following Cities: East LA, Long Beach, Norwalk, Pomona, El Monte, Lynwood, Palmdale, Wilmington, Inglewood, Metro LA, Panorama City, West LA, Lincoln Heights, South L.A.