A Framework for Medicaid Programs to Address Social Determinants of Health: Food Insecurity and Housing Instability

Publication Year: 2017
Patient Need Addressed: Food insecurity, Homelessness/housing
Population Focus: Medicaid beneficiaries
Intervention Type: Best practices
Type of Literature: Grey


Insights Results

Overview of article

  • This article explores the development of a framework for state Medicaid programs to better assess and address social needs in healthcare, using food insecurity as an illustrative example

Methods of article

  • To develop the framework, the expert panel directed a literature review and environmental scan of measures that assess food insecurity and housing instability. They then developed the framework and provided recommendations on how Medicaid programs can support the role of healthcare organizations in addressing social determinants of health


  • The resulting framework positions Medicaid programs as the central entity. Outside of Medicaid programs is SDOH targeted healthcare and SDOH informed healthcare (SDOH Informed Healthcare involves using information on social needs in clinical decision making for Medicaid beneficiaries while SDOH Targeted Healthcare involves connecting individuals to nonhealth services that can address SDOH). This also highlights the role of SDOH data in delivering more effective healthcare
  • There are 9 factors that feed into the central part of the framework: 1) Home and community-based services; 2) Philanthropy; 3) Housing support; 4) Transportation services; 5) Employment services; 6) Social support services; 7) Food and nutritional support; 8) Public health; and 9) School-based clinics
  • While assessing food insecurity, many measures and practices emerged. For example, there is the USDA’s Household and Food Security Survey Model (FSSM), the Current Population Survey Food Security Supplement, the American Housing Survey and more. Notably, the validated Hunger Vital Sign tool is a 2-question screening tool that allows clinicians to identify households at risk for food insecurity
  • Although existing tools track affordability, access, variety, and preferences, these tools may not adequately evaluate whether the food that respondents eat fulfills nutritional needs to encourage healthy living, particularly for those with conditions that require a more limited diet
  • There are also several emerging strategies for addressing food insecurity. For example, AARP
    recommends using the American Academy of Pediatrics (AAP) 2-item screener to document food insecurity in electronic health records (EHR) and the referral generated in the EHR. An outreach team then follows up with the patient by phone, mail, or in person
  • The strategies involve linking primary care practices with community partners. For instance, Maryland Hunger Solutions conducts on-site SNAP application screening and enrollment for food insecure patients at Chase Brexton Health in Baltimore. In addition, the Pathways Community HUB Model, which relies on community care coordinators (CCC), helps to conduct outreach to at-risk individuals through home visits and community-based work
  • A tool that assesses housing instability includes the American Community Survey. However, there are surveys that assess the relationship of housing instability to other social risk factors, health and wellbeing. These include The Behavioral Risk Factor Surveillance Survey, Three City Study Survey, Fragile Families and Child Wellbeing Survey, National Survey of American Families, the National Survey of Child and Adolescent Well-Being, and the Panel Study of Income Dynamics
  • There are promising practices that aim to leverage collaborations between the community and healthcare system. For instance, Camden Coalition of Healthcare Providers started an initiative known as “healthcare hot spotting” that focuses on high utilizers of hospital care
  • One of the most promising data collection activities is the Accountable Health Communities Model, which aims to provide comprehensive screening of the social needs of community dwelling Medicare and Medicaid beneficiaries. Medicaid programs, bridge organizations, community service providers, and clinical delivery sites are working together to screen and coordinate care to address housing instability and food insecurity among other social needs. Participating organizations are required to report information on both food insecurity and housing instability and how screening affects clinical
  • Examples of how states are beginning to collect data related to food insecurity and housing instability include:
    1) Massachusetts’s Social Determinant of Health Model, which allows the Medicaid program to risk adjust for social risk factors. The state linked claims data, plan encounter data, and data from other state agencies as well as the U.S. Census Bureau to develop measures that assess factors like unstable housing and neighborhood stress
    2) Minnesota has built a large SDOH data set by extracting elements from claims data, EHRs, state and federal databases, and patient self-reported instruments. Patient assessment instruments that assess food insecurity and housing instability at the patient level include the Accountable Health Communities tool, Health Leads, and the PRAPARE tool
    3) New Jersey’s 1115 waiver that targets funding at housing support services to individuals who are homeless or are at risk of being homeless. The program is also aiming to enhance population health
    partnerships with community and faith-based organizations, public health organizations, employers, and other stakeholders to improve outcomes for beneficiaries. Sharing beneficiary information across state agencies and implementing data use agreements that ensure confidentiality have supported and strengthened these initiatives
    4) Connecticut has embedded several strategies to connect programs to address social factors. The agency has been able to integrate screening of housing stability and food security through its Administrative Services Organization structure and Intensive Care Management. It has also increased SDOH targeted care through health homes, the Money Follows the Person “housing plus services” model, and development of an upside-only shared savings initiative
    5) Pennsylvania developed the COMPASS website, which allows individuals and community-based organizations to screen, apply for, and renew benefits across a range of programs. These programs include SNAP, free or reduced price school meals, home and community-based services, and the Low Income Home Energy Assistance Program
    6) Oregon developed a data inventory to help people find affordable housing more easily. The inventory provides a list of affordable properties in a user-friendly format and integrates data from Oregon Housing and Community Services, HUD, U.S. Department of Agriculture and Rural Development, and the Oregon Opportunity Network. Oregon’s Health Authority has also developed a provider-level food insecurity screening performance measure that coordinated care organizations (CCOs) can choose for reporting and accountability
    7) Illinois has a long-standing integrated system, which determines eligibility for medical programs, SNAP, and Temporary Assistance for Needy Families
    8) Louisiana, through its 1915c waiver, has integrated its Permanent Supportive Housing program (PSM) with its Home and Community Based Services (HCBS) program. HCBS providers, particularly those involved in health and housing services, assist in enrolling eligible patients with a focus on individuals who are homeless

Key takeaways/implications

  • The Expert Panel provided 6 recommendations to support the implementation of the framework with input from NQF members, the public, and key informants. The Panel categorized its recommendations into the following areas: 1) Community and healthcare system linkages; 2) Information sharing and measurement; 3) Payment methods and innovative use of resources
  • Recommendations: 1) Acknowledge that Medicaid has a role in addressing social determinants of health; 2) Create a comprehensive, accessible, routinely updated list of community resources; 3) Harmonize tools that assess social determinants of health; 4) Create standards for inputting and extracting social needs data from electronic health records; 5) Increase information sharing between government agencies; 6) Expand the use of waivers and demonstration projects to learn what works best for screening and addressing SDOH
  • Future work should focus on when patient-level versus population-level measures are feasible and/or appropriate for use. For instance, when area-based measures (e.g., Massachusetts Medicaid neighborhood stress score) are appropriate for use for payment and/or risk adjustment