Social Need Screening and Intervention (SNS-E)

The percentage of members who were screened, using prespecified instruments, at least once during the measurement period for unmet food, housing and transportation needs, and received a corresponding intervention if they screened positive.

• Food Screening. The percentage of members who were screened for food insecurity.
• Food Intervention. The percentage of members who received a corresponding intervention within 30 days (1 month) of screening positive for food insecurity.
• Housing Screening. The percentage of members who were screened for housing instability, homelessness or housing inadequacy.
• Housing Intervention. The percentage of members who received a corresponding intervention within 30 days (1 month) of screening positive for housing instability, homelessness or housing inadequacy.
• Transportation Screening. The percentage of members who were screened for transportation insecurity.
• Transportation Intervention. The percentage of members who received a corresponding intervention within 30 days (1 month) of screening positive for transportation insecurity.

Why It Matters

Social determinants of health (SDOH) are defined as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life,” including economic policies and systems, development agendas, social norms and political systems.¹ Social needs have considerable impact on health inequity and can include inadequate access to nutritious food, transportation barriers and inadequate or unstable housing.^2,3

• Food. Food Insecurity, defined as the disruption of food intake or eating patterns because of lack of money and other resources, affected approximately 12.8% of American households at some time during 2022.^4,5 This prevalence increases to 17.3% when there are children in the household.⁵ Food insecurity may also make it challenging for individuals to afford or adhere to appropriate diets to properly manage their medical conditions and is closely associated with decreased nutrient intake, poorer health and increased rates of chronic disease, behavioral and mental health conditions in all individuals.^6,7 Interventions at the health plan level include identifying members living with food insecurity through screenings, referring members and their families to food banks and assistance programs and creating new food distribution programs.⁸
• Housing. Housing barriers can be experienced as housing inadequacy, housing instability and homelessness. Housing inadequacy may be defined as difficulty obtaining safe, adequate and affordable housing, where housing instability may refer to challenges such as difficulty paying rent, overcrowding or moving frequently.^9,10 As of January 2021, 18 out of every 10,000 Americans experienced homelessness. ¹¹ Housing issues have been linked to a multitude of health outcomes, including self-reported health, stress, depression, anxiety and premature death. Once a housing need is identified, follow-up interventions can include assistance with housing coordination, counseling and education, or referral to housing support services. Plan-level interventions can include paying for services such as housing location services, eviction prevention services, and training on tenant rights and responsibilities.¹²
• Transportation. The American Hospital Association reports that 3.6 million individuals forgo needed medical care each year due to inadequate access to transportation. Transportation barriers occur for a variety of reasons, including, but not limited to, public transportation infrastructure, health care provider supply, transportation costs, vehicle access and time burden.¹³ Missed appointments, or “no-shows,” have been linked to lower rates of preventive care, poorer health outcomes and higher acute-care utilization. Organizations can address transportation barriers by understanding the drivers of inadequate transportation among their patients, assessing individual transportation access, partnering with community organizations to address transportation needs and supporting policies to improve transportation infrastructure and access in their communities.¹³ Examples of interventions that organizations are pursuing to address transportation barriers among their patients include partnering with ride-sharing services to provide transportation to medical appointments and enhancing virtual care access. Some studies have shown a decrease in patient no-shows after implementation of ride-sharing programs.¹⁴ At the health plan level, CMS recently expanded the type of transportation benefits MA plans are able to provide—including coverage for nonmedical transportation.¹⁵

A growing number of guidelines and clinical practice policies in the U.S. relate to screening for social needs and linkage to resources. Some of these recommendations include following guidance on how to engage patients in screening conversations,¹⁶ expanding SDOH screening tools and supporting payment reform policy that incentivize for SDOH screening and referral.² Additional recommendations include screening children for social risk factors during all patient encounters and partnering with community organizations, intervention programs and schools to link patients to needed resources. ¹⁷

Results

Data not available to display at this time.