Screening for health-related social needs (HRSN) is evolving into a care standard.
Value-based care contracts and accreditation bodies are beginning to require screening for social determinants of health (SDOH) and social needs.
The Joint Commission now asks healthcare organizations to assess HRSNs for a representative sample of their patients. Their focus on health-related social needs highlights the needs of individuals versus social determinants of health that describe population characteristics and influences.
Health systems, ambulatory settings, and health plans will begin to see more screening requirements for HRSN or SDOH. However, most will leave the choice of which tool or questions to use up to the healthcare organization.
While there has been little research into health-related social needs or SDoH assessment tools, several have been validated and reviewed. These options are in alignment with the Institute of Medicine's (IOM) recommendations and other healthcare quality organizations' requirements.
Despite a proven link between SDOH and health outcomes, a 2020 Population Health Management research review estimated that 50% of patients with social needs could be missed by failure to screen routinely.
According to the National Academies of Sciences, social needs should be screened into five main categories, including:
In 2014, the IOM convened a committee to identify which social and behavioral domains most strongly correlated with health. The committee recommended 11 candidate SDoH data domains, including education, financial resources, race/ethnicity, social support, violence, and neighborhood.
More recently, CMS suggested prioritizing screening for SDOH domains that can be addressed through community services, including:
Equipped with appropriate screening tools, clinical and non-clinical staff can uncover a patient’s health-related social needs and use that information to create effective care management plans.
The following social needs assessment tools are among those provided as resources by the Joint Commission, along with many other screening support materials and education.
While some tools focus on a single social need area (i.e., food insecurity), others focus on multiple factors.
When vetting and implementing a screening tool, healthcare leaders should tailor it to meet the unique needs of their SDOH or care management program, patient population, and programmatic goals.
Consider these steps when adapting or adopting a screening tool:
Once you’ve vetted and selected your HRSN screening tool, implement a regular review of SDOH data output. Look at how its collection is connected to addressing social needs and improving health outcomes.
When social needs data input and output align well with available community resources, care management programs can make a measurable impact on patient health and support quality and payment incentives.
ThoroughCare can help assess social barriers as part of patient–centered care planning.
Healthcare organizations use ThoroughCare to deliver integrated care management services to foster patient engagement and enhance revenue. Our platform provides the digital infrastructure to leverage fee-for-service programs for value-based success.
With seamless EHR integration and data interoperability across health information exchanges and remote devices, our platform supports solutions for:
Providers use ThoroughCare to seamlessly manage populations, capture and act on patient data with interactive care planning and assessments, and visualize business performance to inform decision-makers.