Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool - National Academy of Medicine (2025)

By Alexander Billioux, Katherine Verlander, Susan Anthony, and Dawn Alley

May 30, 2017 | Discussion Paper

The impacts of unmet health-related social needs, such as homelessness,inconsistent access to food, and exposure to violence on health and health careutilization, are well-established. Growing evidence indicates that addressing these and other needs can help reverse their damaging health effects, but screening forsocial needs is not yet standard clinical practice. In many communities, the absence of established pathways and infrastructure and perceptions of inadequate time tomake community referrals are barriers that seem to often keep clinicians and theirstaff from broaching the topic. The Centers for Medicare & Medicaid Services (CMS)Accountable Health Communities Model, tested by the Center for Medicare andMedicaid Innovation, addresses this critical gap between clinical care and communityservices in the current health care delivery system by testing whether systematicallyidentifying and addressing the health-related social needs of Medicare and Medicaidbeneficiaries impacts their total health care costs and improves health.

With input from a panel of national experts and after review of existing screening instruments, CMS developeda 10-item screening tool to identify patient needsin 5 different domains that can be addressed throughcommunity services (housing instability, food insecurity,transportation difficulties, utility assistance needs,and interpersonal safety). Clinicians and their staff canuse this short tool across a spectrum of ages, backgrounds,and settings, and it is streamlined enough tobe incorporated into busy clinical workflows. Just likewith clinical assessment tools, results from this screeningtool can be used to inform a patient’s treatmentplan as well as make referrals to community services.

Introduction

Evidence demonstrates that non-medical health-related social needs (HRSNs), such as housing instability, food insecurity, and exposure to interpersonal violence, drive health care utilization and impact health outcomes [1, 2, 3]. Clinicians routinely employ standardized questions and validated assessment tools to screen for clinical and behavioral drivers of poor health, such as alcohol dependency, decompensated heart failure, and depression, but screening for HRSNs is not yet standard clinical practice [4, 5, 6]. Standardized application of screening tools as a part of clinical routines allows provider teams to quickly and consistently identify possible health needs for further investigation and intervention. A variety of assessment tools have been developed to help health providers identify the presence of deleterious social circumstances, and a few recent studies have demonstrated the efficacy of screening tools combining several HRSN domains in identifying various HRSNs of patients and their caregivers [7, 8, 9]. However, inadequate training, perceptions of inadequate time to investigate social needs, and, importantly, the absence of established pathways and infrastructure to address identified unmet needs are barriers that often keep clinicians and their staff from implementing HRSN screening at their clinical delivery sites [10, 11, 12]. The Centers for Medicare & MedicaidServices (CMS) Accountable Health Communities (AHC)Model will test whether addressing these delivery system barriers through universal HRSN screening andenhanced clinical-community linkages can improvehealth outcomes and impact costs [13].

CMS developed the AHC Model to address a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the HRSNs of Medicare and Medicaid beneficiaries impacts total health care costs and utilization, increases the quality of care, and improves health. Through the model, CMS will support clinical and community partnerships—coordinated by a “backbone” organization—among clinical delivery sites, community service providers, and state Medicaid agencies. Clinical delivery sites—hospitals, clinics, doctors’ offices, and other clinical settings—will serve as the crucial entry point for the model by serving as the place of screening for all Medicare and Medicaid beneficiaries for unmet needs across five core HRSN domains: housing instability (e.g., homelessness, poor housing quality), food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety concerns (e.g., intimate-partner violence, elder abuse, child maltreatment). Individual communities may also elect to screen across several supplemental HRSN domains, including family and social supports (e.g., respite and caregiver support services, child care, social isolation), education, employment and financial strain, health behaviors (e.g., tobacco use, alcohol and substance use, physical activity), mental health, and disabilities. To ensure consistency in the screening offered to beneficiaries across both an individual community’s clinical delivery sites and across all the communities in the model, CMS developed a standardized HRSN screening tool. This paper describes the considerations and processes that shaped the screening tool, including the component questions and evidence supporting their inclusion, as well as the potential role the tool can play in facilitating screening for HRSNs in clinical settings across the U.S. health care system.

Tool Development: Design Principles and Expert Consultation

Out of the many non-medical needs that impact health,CMS selected five core HRSN domains based on thefollowing criteria: 1) high-quality evidence exists linkingthe HRSN to poor health or increased health careutilization and cost; 2) the need can be met by communityservice providers; and 3) the need is not systemicallyaddressed by health care providers. In developing the AHC HRSN screening tool for the five core domains, CMS followed three guiding principles.

First, the tool needed to consistently identify the broadest set of HRSNs that could be addressed bycommunity service providers. Ideally, the screeningtool would identify any unmet need within an inclusivefocal area likely to have a negative impact on health,rather than specifying a particular subset of needs. Thetool would allow clinical delivery sites to identify broadneeds and engage navigators and community serviceproviders, who are better suited to identify more specificneeds and address the individualized issues thatunderlie unmet need. For example, the AHC HRSN screening tool would identify that an individual is at risk for food insecurity broadly, and the care navigatoror community service provider would identify theindividual’s specific drivers of food insecurity, such asdifficulty obtaining food near the end of pay periods ordaily need for food assistance.

Second, the tool needed to be simple and streamlined to ensure that its questions were readily understandableto the broadest audience across a varietyof settings, as well as to allow for inclusionof routine screening in busy clinical workflows [14]. Medicare andMedicaid beneficiaries represent a diverse subset ofthe U.S. population and include individuals of all agesand backgrounds, and AHCs will span rural and urbanareas across the United States. AHCs will work to make the tool accessible to beneficiaries regardless of language,literacy level or disability status, further broadening its applicability. Additionally, because AHC clinical delivery sites have the option to allow beneficiaries to self-administer the screening tool, simplicity in designand language were key considerations in order toreduce the need for outside assistance.

Finally, the tool needed to be evidence-based and informed by practical experience. CMS began by conducting a review of existing screening tools and questionsfocused on the core and supplemental HRSN domains listed above. Through this process, over 50screening tools totaling more than 200 questions werecompiled. In order to refine this list, CMS consulteda technical expert panel (TEP) consisting of a diversegroup of tool developers, public health and clinicalresearchers, clinicians, population health and healthsystems executives, community-based organization leaders, and federal partners (Box 2). Over the courseof several meetings, this TEP came together to discussopportunities and challenges involved in screening forHRSNs; consider and pare down CMS’s list of evidence-basedscreening questions; and recommend a short list of questions for inclusion in the final tool.

The AHC Health-Related Social Needs Screening Tool

Based on the recommendations of the TEP, CMS developeda 10-question screening tool (the AHC HRSNscreening tool) to identify unmet needs across fivecore domains. Questions in the AHC screening toolare meant for an individual respondent and should beanswered by individuals themselves, or by a parent orcaregiver on an individual’s behalf. The tool is designedto be short, accessible, consistent, and inclusive. Thefull AHC HRSN screening tool for use in the AHC Modelwill also include questions to identify a beneficiary’seligibility for the model, standard demographic questions for evaluation purposes, and screening questionsfor supplemental domains, if applicable. Developmentof these sections is not the focus of this paper. The followingdescribes the development of questions for the10-item AHC HRSN screening tool for the core HRSNs.

Housing Instability

Unmet housing needs may include homelessness,poor housing quality, or inability to pay a mortgageor rent. Acknowledging that perception of need maybe different for various housing situations, the TEP recommended including examples of homelessnessand substandard housing in the tool. After reviewingvalidated and common housing questions, the TEPrecommended inclusion of two questions for this domain(Box 1).

The first housing question is adapted from the Protocol for Responding to and Assessing Patients’ Assets,Risks, and Experiences (PRAPARE) assessment tooldeveloped by the National Association of CommunityHealth Centers and partners [15]. The first answeroption is intended to identify beneficiaries who arehomeless. Accordingly, the TEP recommended adding“abandoned building, bus or train station” to the examples offered to better align with the federal definitionof “homeless” [16]. The second answer optionis intended to identify beneficiaries who are at risk of losing their housing for any reason, including the inabilityto pay a mortgage or rent. Selecting either option1 or option 2 would indicate that the beneficiary hasa housing need for the purposes of the AHC Model.The second housing question is adapted from a questiondeveloped by Nuruzzaman and colleagues andis intended to identify beneficiaries who are living in substandard housing [17]. Selecting any answer optionother than “none of the above” would indicate that thebeneficiary has a housing need for the purposes of theAHC Model.

Food Insecurity

The U.S. Department of Agriculture (USDA) defines foodsecurity as “access by all people at all times to enoughfood for an active, healthy life.” The AHC HRSN screeningtool will include two questions, recommended bythe TEP, to identify food insecurity among community-dwellingMedicare and Medicaid beneficiaries in theAHC Model (Box 1). CMS adapted these questions from the Hunger Vital SignTM, a published two-question foodinsecurity screening tool that has shown to be sensitive,specific, and valid when asked of low-income familieswith young children [18]. The American Academyof Pediatrics recommends that pediatricians screen allchildren for food security using this two-item screeningtool [19]. The questions in the two-item screeningtool are also part of the full 18-item USDA U.S. HouseholdFood Security Survey [20]. The TEP recommendedchanges to the introductory text and question stemsin order to match the voice of the other AHC screening tool questions. Selecting “often true” or “sometimestrue” for either question would indicate that the beneficiaryis food insecure or at risk of food insecurity forthe purposes of the AHC Model.

Transportation Needs

Unmet transportation needs encompass lack oftransportation to get to any destinations neededfor daily living. The TEP suggested differentiatingbetween medical and non-medical transportation needs in order to help target the resources suggested during referral and navigation. The AHC screeningtool will include one question to identify any unmettransportation needs among community-dwellingMedicare and Medicaid beneficiaries in the AHCModel (Box 1). This question was adapted from thePRAPARE assessment tool. Selecting any answer optionother than “no” indicates that a beneficiary has a transportationneed for the purposes of the AHC Model.

Utility Needs

When screening for a beneficiary’s difficulty paying utility bills, the TEP recommended listing specific utilities for clarity and adding furnace oil as an example to address regional variation in utilities. After reviewing validated and common questions on utility needs, the TEP recommended one question for inclusion in the AHC HRSN screening tool. This question is adapted from the validated Children’s Sentinel Nutrition Assessment Program (C-SNAP) survey [21]. Selecting any answer optionother than “no” would indicate that the beneficiary hasa utility need for the purposes of the AHC Model.

Interpersonal Safety

The AHC HRSN screening tool includes four questionsrelated to interpersonal safety, including exposure tointimate partner violence, elder abuse, and child abuse.CMS adapted these questions from the Hurt, Insult,Threaten, and Scream (HITS) instrument, which has been validated in multiple settings around the worldfor use as a self-report or clinician-administered toolto identify intimate partner violence among womenand men [22, 23, 24]. In order to broaden the scope ofthese questions beyond intimate partner violence, theTEP recommended editing the question stems to say “anyone, including family” instead of “your partner.”The HITS instrument is scored as a whole. Each answeroption is numbered sequentially from 1 to 5 points,where “never” is 1 point and “frequently” is 5 points.Thus, scores for this domain range from 4-20. A scoreof greater than 10 would indicate that the beneficiary isexperiencing or at risk of interpersonal violence for thepurposes of the AHC Model.

The TEP made special recommendations regarding the framing and placement of the interpersonal safety questions because of the sensitive nature of this topic. For example, the TEP recommended introducing these questions with the following normalizing language: “Because violence and abuse happens to a lot of people and affects their health, we are asking the following questions.” The TEP also recommended that the screeningtool ask the questions on interpersonal safety laterin the screening to give an opportunity for staff to firstbuild rapport with beneficiaries when they deliver the tool face-to-face.

Discussion

The impacts of unmet HRSNs, such as homelessness, inconsistent access to food, and exposure to interpersonal violence, on health care utilization and individual health are well established [1, 2, 3]. Fortunately, growing evidence indicates that addressing these and other needs can help reverse their deleterious health effects [25, 26, 27]. While some health care systems like Hennepin Health in Minnesota and Kaiser Permanente inCalifornia have pioneered efforts to connect memberswith unmet needs to community services, broaderadoption of such programs is contingent on the developmentof approaches scalable across a variety ofcontexts [28, 29]. Regardless of the approach, the foundationalstep to addressing unmet HRSNs is to supportclinicians and staff in identifying them, as through theuniversal application of a clinical screening tool like theone described in this paper.

A growing body of screening tools and surveys has been developed to aid in individual- and community levelsocial needs assessments or population risk adjustments[30, 31, 32]. The AHC HRSN screening tool,however, was specifically developed to identify HRSNsthat negatively impact health and health care utilization,and, importantly, can be addressed through communityinterventions. Furthermore, the tool is uniquein that it combines screening across 5 key domains ofHRSNs into only 10 questions. Few social need screeningtools achieve the same breadth with similar brevity.The AHC HRSN screening tool’s breadth increases the likelihood that significant needs will be identified, aswell as presents an opportunity to evaluate the impact of assessing multiple domains at one time. Meanwhile,the tool’s brevity and simplicity enable it to be integratedinto crowded clinical workflows while remaining accessibleto a diverse group of patients. These qualitiessupport the universal application of the tool to screenall individuals seeking care, thereby reducing the riskof missed unmet needs through provider-triggered
screening [9].

While the attributes discussed above facilitate the clinical application of this HRSN screening tool, severallimitations are worth noting. First, the tool’s questionsfocus solely on the core and supplemental HRSN domainsaddressed in the AHC Model and do not representa comprehensive screen of all HRSNs. The 2014report from the Institute of Medicine (IOM) on capturing social and behavioral measures in electronic health records (EHRs) identified 17 domains that had validmeasures that could be incorporated into EHRs [33].Although most of the domains described in the IOMreport are also included as either core or supplementaldomains for this AHC HRSN screening tool, othersare not included because the domain did not meet theinclusion criteria discussed above. For example, countryof origin is a domain identified by the IOM report,but does not qualify as a need that interventions couldchange, and health literacy is an IOM report domain,but is not commonly addressed by community serviceproviders to which patients could be referred. Second,the questions are broadly worded, limiting the abilityto delineate specific types of need within each domainexplored. This tradeoff was consciously made in orderto identify the largest proportion of clinically significantneeds in the fewest questions. Finally, although the toolis based on commonly used or evidence-based questionsrecommended by an experienced panel of technicalexperts, several questions have been modified oradapted and have not been tested as a unit and in thisformat previously, which may impact their validity or reliability.The tool will be delivered in a variety of formats(i.e., both paper-based and electronic, staff-administered and self-screened, and in multiple languages), toa wide range of ages, and in a number of different clinicalsettings (e.g., primary care clinics, behavioral healthcenters, and emergency departments). As a result, CMSwill monitor the tool’s performance across AHC participantsand consider making future updates to its designbased on feedback gained through its practical application.

Conclusion

Identifying the burden of unmet HRSNs is the criticalfirst step to connecting individuals to resources in theircommunities that can address those needs and, as aresult, improve their health. The AHC HRSN screeningtool was designed to accomplish this function forseveral key non-medical drivers of health in a way thatis broadly applicable across a spectrum of ages, conditions,backgrounds, and settings, while remaining streamlined enough to be incorporated into busy clinicalworkflows. Applying this tool in the AHC Model willhelp CMS to evaluate the impact of local partnershipsamong health care providers and community serviceorganizations—working toward common goals andempowered by shared data and tools—in advancingthe aims of addressing the cost and quality of healthcare across all settings, and safeguarding the health ofour nation.

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Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool - National Academy of Medicine (2025)
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