Resolution or Improvement of a Health-Related Social Need
Measure Description
Percentage of patients 18 years or older who screen positive for 1 or more of the 5 core health-related social needs (HRSNs), including food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety; and have at least 1 of their HRSNs resolved or improved within 6 months.
Relevance to Value Based Care
Health-related social needs encompass a range of non-medical factors that influence an individual's health status, including socioeconomic status, housing stability, food security, access to transportation, social support networks, and exposure to discrimination or violence. Research demonstrates that these social determinants significantly impact a person's ability to maintain good health, adhere to treatment plans, and access appropriate healthcare services. By recognizing and addressing these needs, clinicians can help patients overcome barriers to accessing healthcare, improve treatment adherence, and enhance overall well-being.
Numerator
Patients who report resolution of at least 1 health-related social need or improvement to distress score within 6 months.
NUMERATOR NOTE:
Improvement is defined as a reduction in the patient’s overall distress score or level of response severity (i.e. always vs. sometimes vs. rarely). Resolution is defined as the patient indicates that they no longer need assistance for 1 or more HRSNs that were identified during initial screening. The absence of a HRSN charted during a subsequent screening is indicative of resolution.
If more than one screen occurs during the 6-month follow up, refer to the latest (most current) screening results. If needed, at the request of the patient it is appropriate for a family member or caregiver to assist with the completion of screen.
Denominator
All patients 18 years or older who screened positive for one or more of the 5 core domains included in a standardized HRSN screening.
Denominator Criteria (Eligible Cases):
Patients aged 18 and older during the performance period AND
Two patient encounters during the performance period
Definitions: 5 Core Domains:
food insecurity
housing instability
transportation needs
utilities difficulties
interpersonal safety
Denominator Identification Period – July 1st of the previous performance period through June 30th of the current performance period.
Examples of standardized HRSN Screening Tools include the following, but are not limited to:
NCCN Distress Thermometer
Accountable Health Communities Health-Related Social Needs Screening Tool
The Protocol for Responding to and Assessing Patients’ Risks and Experiences (PRAPARE) Tool
WellRx Questionnaire
American Academy of Family Physicians (AAFP) Screening Tool
Denominator Exclusion
Patients who have died prior to 6-month follow up. Patients who are actively enrolled in hospice during the 6-month follow up.
Denominator Exception
Patient declined assessment. Patient declined assistance.
Telehealth:
Yes
Scoring
New measure in it's first year: 7-point floor, unless same year benchmark established then 7-10 points.
RESOURCES