Editor’s Note: This post was originally published in June 2017 and has been updated in December 2019 for accuracy and comprehensiveness.
Nine in ten physicians serving low-income communities believe patients’ social needs are as important to address as their medical conditions. Similarly, based on our research, patients are comfortable with being asked questions in clinical settings about their social needs.
But according to the Centers for Medicare & Medicaid Services (CMS), screening for social needs is not yet standard clinical practice due to "the absence of established pathways and infrastructure and perceptions of inadequate time to make community referrals."
CMS Social Needs Screening Tool
CMS has created a 10-item screening tool to identify patient needs across five domains of social needs. The tool was designed to be "short, accessible, consistent, and inclusive," with input from experts at Kaiser Permanente, Boston Children's, Hennepin Health, and other organizations. The tool has been shown to identify a SDOH need in more than 75 percent of those screened.
The 10-item screening covers five domains of social needs:
- Housing instability including homelessness, poor housing quality, or inability to pay a mortgage or rent, with two questions adapted from the PRAPARE assessment tool and a study published in the Journal of Health Care for the Poor and Underserved.
- Food insecurity with two questions adapted from the Hunger Vital Sign tool.
- Transportation needs, both medical and non-medical in nature, with one question also adapted from the PRAPARE assessment tool.
- Utility needs, specifically screening for difficulty paying utility bills, with one question adapted from a Children’s Sentinel Nutrition Assessment Program (C-SNAP) survey.
- Interpersonal safety related to intimate partner violence, elder abuse, and child abuse, with four questions adapted from the Hurt, Insult, Threaten, and Scream (HITS) instrument.
→ Access the screening tool and research paper from the National Academy of Medicine here.
→ Access a 10-page explainer about the screening tool from CMS here.
Accountable Health Communities: 2020 Update
This screening tool was created to support the CMS Accountable Health Communities Model which is currently testing how well universal social needs screening and enhanced clinical-community linkages can improve health outcomes and impact costs of care.
According to the Office of Minority Health at CMS, the model is based on emerging evidence that shows addressing health-related social needs through enhanced clinical-community links can improve health outcomes and reduce costs. The model also helps to foster innovation to support connections between care, food, and housing for patients in need.
In 2020, Abt Associates is responsible for evaluating the AHC model by providing community profiles, a beneficiary survey, and interviews and a survey of community service providers involved in the program.
SDOH Expert Panel Convened by CMS
An expert advisory panel contributed to the development of the social needs screening tool. The panel included the following individuals:
- Michael Bilton, Senior Director, Community Health and Benefit, Dignity Health.
- Jacquelyn Campbell, National Program Director, RWJF Nurse Faculty Scholars.
- George Carter, Social Science Analyst, HUD’s Office of Policy Development and Research.
- Amanda Cash, Senior Advisor for Evaluation & Evidence, HHS's Office of the Assistant Secretary for Planning and Evaluation.
- Jon Delman, Senior Researcher and Evaluator, Technical Assistance Collaborative.
- Dr. Eric Fleegler, Emergency Medicine Physician and Health Services Researcher, Boston Children’s Hospital.
- Dr. Deborah Frank, Founding Director, Grow Clinic for Children, Boston Medical Center & Founding National Principal Investigator, Children’s HealthWatch.
- Amy Freeman, Vice President, Ascension Health, President and CEO for Community Health.
- Dr. Arvin Garg, Associate Professor of Pediatrics, Boston University School of Medicine and Boston Medical Center.
- Nancy Garrett, Chief Analytics Officer, Hennepin County Medical Center.
- Dr. Donna Persaud, Senior Medical Director, Parkland Center for Clinical Innovation.
- Michelle Proser, Director of Research, National Association of Community Health Centers.
- Amanda Reddy, Director of Strategy and Impact, National Center for Healthy Housing.
- Nanette Relave, Senior Director of National I&R Support Center, National Association of States United for Aging and Disabilities.
- Dr. Nirav Shah, Senior Vice President & Chief Operating Officer for Clinical Operations, Kaiser Permanente’s Southern CA.
- Madeleine Shea, Deputy Director, Office of Minority Health, CMS.
- Sarah Szanton, Associate Professor, Johns Hopkins University School of Nursing and School of Public Health.
- Anita Yuskauskas, PhD Coordinator and Instructor, Health Policy and Administration Program, Pennsylvania State University.