Achieving Health Equity
Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:
- Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or
- Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or
- Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources.
Drivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.
Improve the screening and documentation of drivers of health needs using evidence-based tools.
Evidence of screening for the drivers of health, specified by the MIPS eligible clinician for this activity, and documentation of actions taken to address any identified needs. In addition to the drivers of health listed in the activity description, drivers of health prioritized by the MIPS eligible clinician may include others (e.g., transportation accessibility; interpersonal safety; legal challenges; and environmental exposures). Include the first element and one of the following elements:
1) Use of a validated patient drivers of health 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 should be electronically enabled and include 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 drivers of health needs to patients with those 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 an need related to drivers of health and documents follow-up with identified patient(s).
- Drivers of health 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-9-2-1... 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 drivers of health/health-related social needs in primary care settings: https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-m....