Finding & Using Validated Assessments For Care Management & SDoH Needs

The connections among health-related social needs, value-based care, and care management are becoming tighter.

The Joint Commission now requires hospitals to collect specific social determinants of health (SDoH) information, particularly regarding individual health-related social needs (HRSN). And, as Medicaid and Medicare transition more to managed care and value-based contracts, assessing social needs is becoming more commonplace and is included across key programs, including the 2024 Medicare Advantage Star Ratings program, aligned with the CMS Framework for Health Equity. Some states, like North Carolina, require it.

To date, there has been little research into HRSN or SDoH assessment tools. However, a cadre of tools has been validated and reviewed in terms of how they align with the Institute of Medicine's recommendations and the requirements of other healthcare organizations with a quality focus.

Similar to our review of social risk indices, we want to provide an overview of commonly used social needs assessment tools that can be vetted and used as part of an SDoH, HRSN, or care management program. In a future article, we will explore how to use area-level data, coupled with data from tools like these, to create a risk-stratified view of individual patients or populations.

Health-related social needs and social need assessment adoption

A 2020 review of research published in Population Health Management estimated that 50% of patients with social needs may be missed by failure to screen routinely.

Measuring individual social risk includes social and relational factors that have a proven influence on a person's health outcomes. The National Academies of Sciences organizes social risk factors into 5 areas:

1. Socioeconomic position
2. Race, ethnicity, and cultural circumstances
3. Gender
4. Social relationships
5. Residential and community environment

Specifically, specialized screening tools enable clinical and non-clinical staff to assess and monitor patient social needs and risk factors within payer and provider settings.

The stage is set for prioritizing social & behavioral domains for social risk

In 2014, an Institute of Medicine (IOM) committee was convened to identify “social and behavioral domains that most strongly determine health." They recommended 11 candidate SDoH data domains, focusing on violence, education, financial strain, race/ethnicity, social support, and neighborhood income.

Today, social needs assessment tools should follow their recommendations and collect information that meets these criteria:

• Availability and standardization of reliable, valid measures
• Evidentiary association with health outcomes
• Feasibility of collecting and general accessibility of data
• Sensitivity to a patient's comfort in disclosing information
• “Actionability" when treating patients and developing interventions

More recently, CMS has emphasized screening across the SDoH domains listed above, prioritizing those that can be addressed through community services, including:

• Housing instability
• Food insecurity
• Transportation access
• Utility assistance
• Interpersonal safety

Social needs assessment tools that are validated or commonly used

While various tools are oriented to a specific social needs domain, the following are highlighted for their more widespread approach, adoption, and validation. Of these tools, the majority include the most common domains: interpersonal violence/safety, housing, food insecurity, and financial strain.

HRSN by CMMI: The Health-Related Social Needs (HRSN) Screening Tool is a standard screening tool developed by CMS's Center for Medicare and Medicaid Innovation (CMMI). It includes 10 items categorized into 5 domains: housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety. This tool can be self-administered or used by professionals. It leverages other validated assessments focused on specific unmet social and material needs.

PRAPARE: The Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) is a national standardized patient risk assessment protocol. Their validated assessment tool has been translated into 25 languages and is based on a set of national core measures. PRAPARE is evidence-based, as well as paired with an Implementation and Action Toolkit and standardized across ICD-10, LOINC, and SNOMED.

Health Begins Tool: The HealthBegins screening tool assesses 12 domains and provides a minimum frequency for re-assessment. This tool was developed by a nonprofit organization founded by physicians and public health innovators.

AAFP Form: The American Academy of Family Physicians (AAFP) created an SDoH tool in short and long form in English and Spanish. The short form includes 11 questions on housing, food, transportation, utilities, personal safety, and the level of assistance needed. The tool can be administered by clinical and non-clinical staff or self-administered and includes asking the individual if they want help with any identified needs.

Social Determinants Screening Tool: AccessHealth created a social determinants screening tool as a companion to the Center for Health Care Strategies' brief titled Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations.

Self-Sufficiency Outcomes Matrix: OneCare created this assessment matrix to assess patients' functional health and adequacy of their income, housing, healthcare coverage, and other social supports.

Community Paramedicine Pilot: ThedaCare created their SDoH screening tool as part of the Community Paramedicine pilot, which asks questions about food insecurity, financial strain, transportation, and housing. Patients at moderate or high risk are connected with community resources by a navigator who follows up to increase the chances that patients receive the help they need.

Social Needs Screening Toolkit: The Health Leads Screening Form is a 7-item questionnaire assessing needs in 5 domains, including economic stability, education, social & community context, neighborhood and physical environment, and food. The revised Social Needs Screening Toolkit combines Health Leads' 20+ years of experience implementing social needs programs with well-researched, clinically-validated guidelines from sector authorities like the IOM, CMS, and the CDC.

AHC Screening Tool: The Accountable Health Communities Health-Related Social Needs Screening tool was created by CMS to assess needs in 5 core areas, including housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety. Intended to be completed by an individual, or their caregiver, it also provides several supplemental questions about financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities.

One helpful resource when gathering information on 21 social risk screening tools is Kaiser Permanente's Systematic Review of Social Risk Screening Tools, developed in partnership with the Social Interventions Research & Evaluation Network (SIREN). It provides details on each tool—domains and constructions covered, number of items included, etc.—and published research on its use. SIREN also provides screening tool comparison tables to help users select a tool best suited to their population and needs.

Where is health-related social needs assessment going next?

While there are IOM, CMS, and other governmental guidelines on what should be included in a social needs assessment tool, healthcare teams must tailor their chosen tool based on their unique program, population, programmatic goals, or the available local community resources.

States like North Carolina require or will require SDoH screening to fulfill overall care management requirements in a value-based program. They and other organizations offer recommendations to ensure that a screening tool is built on externally validated questions and is appropriate for use. These recommendations include:

• Ensure your questions are written at an accessible reading level
• Test or pilot any tool before committing to it long-term or scaling to more programs or populations
• Review published research on tools and consult your clinical and operational staff
• Cross-check any new tool with already-captured information to avoid redundant data collection
• Integrate the social needs screening tool into existing workflows
• Harness HRSN information in digital form through an electronic health record (EHR) or other care management platform

If an organization desires to tailor an existing tool or develop a new tool, the North Carolina Department of Health offers the following suggestions:

• Ensure that screening questions include domains where high-quality evidence exists linking them to health outcomes
• Align national, regional, and local resources to the identified needs that you plan to screen
• Confirm that screening questions are simple, brief, and apply to most populations you serve
• Be sure your tool includes a sense of timing—how long a situation has been happening—to determine whether a need is acute or chronic
• Know that one tool doesn't need to address all nuances of need but provide affirmation of some level of need can trigger a more in-depth assessment

Health-related social needs screening tools provide focus to SDoH programs

Regardless of the screening tool chosen, payer and provider teams that manage SDoH programs can test and validate their value. Once validated, those teams can integrate them into existing workflows, promoting universal screening to reduce potential screening bias by staff, and use quality improvement approaches to ensure that the tool acquires accurate and adequate information as well as provides meaningful and actionable output.

Screening can highlight themes of common HRSN among patients, as well as inform engagement and collaboration with community-based organizations that could address patient needs or fill gaps in existing referral networks.

When social need data input and output align well with available resources, SDoH interventions can make a measurable impact on patient health and support value-based incentives.

RTI Health Advance provides full-scale SDoH program support

Whether your team is beginning a new SDoH program and need help with social risk scoring and stratification, or your program is more mature and needs analysis and quality improvement support to transform or enhance outcomes, our team can help. Contact us to discuss your objectives.