Select and screen for the health-related social needs (HRSN) that are relevant for your patient population using tools that have been tested with underserved populations. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded question/field for the capture of data. After screening, address HRSNs identified through at least one of the following:
- Maintain formal relationships with community- based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or
- Update a guide to available community resources, or work with community partners to provide a community resource guide and provide it to patients who are found to be at risk in one or more HRSN area; or
- Record findings of screening and trigger follow-up within the electronic health record (EHR); then analyze EHR data on patients with one or more HRSN needed to identify and implement approaches to better serve their holistic needs through linkages with community resources.
HRSNs prioritized by your practice might include health-harming legal needs, which require both health and legal support to resolve, areas such as food and housing insecurity, or needs such as exercise, nutrition, or chronic disease self-management.
Improve the health and well-being of patients with health-related social needs (HRSN) by connecting them with appropriate community resources.
Evidence of screening for HRSN, specified by the MIPS eligible clinician for this activity, and documentation of actions taken to address any identified needs. In addition to the HRSNs listed in the activity description, HRSNs prioritized by the MIPS eligible clinician may include those listed in the activity description, or others (e.g., access to transportation, federal and state benefits enrollment support, access to assistive technology). Include the first element and one of the following elements:
1) Use of a patient HRSN screening tool – Copy of implemented screening tool (e.g., completed survey or completed verbal assessment) used to identify patients with one or more specified. If feasible, the screening tool is electronically enabled and includes standards-based, coded question(s)/field(s) for the capture of data; AND
2) Provision of community resource guides – Medical record note/field indicating provision of a guide to community resources to meet specified HRSNs to those patients with identified needs. The MIPS eligible clinician should update this guide, or obtain an updated guide from community partners, at least once during the performance year; OR
3) Community referrals – Evidence (e.g., email, Memorandum of Understanding, meeting minutes, data sharing agreement) demonstrating formal relationships with established referral processes between the MIPS eligible clinician and one or more community-based organizations; OR
4) Electronic Health Record (EHR)/registry data analysis – Record of analysis of EHR or registry data that identifies patients with a HRSN and documents follow-up with identified patient(s).
- HRSN Screening Tools that meet the recommended criteria for this activity include: CMS’s Accountable Health Communities screening tool: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf; National Association of Community Health Centers’ PRAPARE assessment: https://www.nachc.org/wp-content/uploads/2020/04/PRAPARE-One-Pager-9-2-16-with-logo-and-trademark.pdf; Health Lead’s Screening Tool: https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/
- Other tools in Kaiser Permanente’s screening tool database: https://sdh-tools-review.kpwashingtonresearch.org/find-tools/submit/715.
- Map screening findings to Z-Codes within EHR systems: https://www.cms.gov/files/document/zcodes-infographic.pdf
- Background on health-related social needs at primary care settings: https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/social-needs-tool.pdf.