The impacts of unmet health-related social needs, such as homelessness, inconsistent access to food, and exposure to violence on health and healthcare utilization, are well-established. Growing evidence indicates that addressing these and other needs can help reverse their damaging health effects, but screening for social needs is not yet standard clinical practice. In many communities, the absence of established pathways and infrastructure and perceptions of inadequate time to make community referrals are barriers that seem to often keep clinicians and their staff from broaching the topic. The Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities Model, tested by the Center for Medicare and Medicaid Innovation, addresses this critical gap between clinical care and community services in the current healthcare delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries impacts their total healthcare costs and improves health.
With input from a panel of national experts and after review of existing screening instruments, CMS developed a 10-item screening tool to identify patient needs in 5 different domains that can be addressed through community services (housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety). Clinicians and their staff can use this short tool across a spectrum of ages, backgrounds, and settings, and it is streamlined enough to be incorporated into busy clinical workflows. Just like with clinical assessment tools, results from this screening tool can be used to inform a patient’s treatment plan as well as make referrals to community services.
Overview of resource
This tool provides an overview of the development and use of The Accountable Health Communities Screening Tool
Methods of resource
With input from a panel of national experts and after review of existing screening instruments, CMS developed a 10-item screening tool to identify patient needs in 5 different domains that can be addressed through community services (e.g., housing instability, food insecurity, transportation, utility assistance needs, and interpersonal safety concerns). This tool is titled the Accountable Health Communities Health-Related Social Needs (AHC HRSN) screening tool
When developing the tool, 3 principles guided its development: 1) The tool needed to consistently identify the broadest set of health-related service needs that could be addressed by community service providers; 2) Needed to be simple and streamlined to ensure questions were readily understandable to broad audiences; and 2) Needed to be evidence-based and informed by practical experience
The 10 items were constructed through insight from a Technical Expertise Panel and adaptations from other tools such as, the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) assessment tool. The 10 items fall under 1 of the 5 domains. The 10 items are: 1) What is your housing situation today?; 2) Think about the place you live. Do you have problems with any of the following? (check all that apply); 3) Within the past 12 months, you worried that your food would run out before you got money to buy more; 4) Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more; 5) In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply); 6) In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?; 7) How often does anyone, including family, physically hurt you?; 8) How often does anyone, including family, insult or talk down to you?; 9) How often does anyone, including family, threaten you with harm?; and 10) How often does anyone, including family, scream or curse at you?
The AHC HRSN tool’s breadth increases the likelihood that significant needs will be identified. Moreover, the tool’s brevity and simplicity enables it to be integrated into crowded clinical workflow while remaining accessible to a diverse group of patients. Together, this supports the universal application of the tool to screen all individuals seeking care, reducing the risk of missed unmet needs through provider-triggered screening
Identifying the burden of unmet HRSNs is the critical first step to connecting individuals to resources in their communities that can address those needs and, as a result, improve their health. The AHC HRSN screening tool was designed to accomplish this function for several key non-medical drivers of health in a way that is broadly applicable across a spectrum of ages, conditions, backgrounds, and settings, while remaining streamlined enough to be incorporated into busy clinical workflows. Applying this tool in the AHC Model will help CMS to evaluate the impact of local partnerships among healthcare providers and community service organizations in advancing the aims of addressing the cost and quality of healthcare across all settings
Limitations to the screening tool include lack of evaluation of all HRSN’s and lack of testing of all questions, which may impact their tool’s validity or reliability