A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool

A New Guide on Universal Screening for Patients’ Social Needs from the Accountable Health Communities Model

Mounting real-world evidence shows that universal screening for health-related social needs in routine clinical care offers a standardized way for health care providers to identify needs, tailor care in response to them, and help patients resolve these needs through referral to community resources. Yet screening for patients’ social needs can seem like a daunting task for clinical providers. One strategy for providers is to first identify patients’ social needs by administering a screening tool such as the one developed for the Accountable Health Communities Model, a nationwide initiative funded by the Centers for Medicare & Medicaid Services (CMS) Innovation Center that is testing the impact of systematically identifying and addressing health-related social needs among Medicare and Medicaid beneficiaries. To help providers administer this Screening Tool, Mathematica developed, on CMS’s behalf, a set of instructions for users called “A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool: Promising Practices and Key Insights.”

The Accountable Health Communities Health-Related Social Needs Screening Tool enables users to quickly assess patients’ social needs from five domains determined to be core needs by CMS (living situation, food, transportation, utilities, and safety) and eight supplemental domains (financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities). The Screening Tool is appropriate for use in a wide range of clinical settings, including primary care practices, emergency departments, labor and delivery units, inpatient psychiatric units, behavioral health clinics, and other places where people access clinical care. The tool is available in three versions: (1) a standard self-administered version, (2) a proxy version with questions adapted to enable someone to answer on behalf of the patient, and (3) a multiuse version that includes language for a proxy as well as for patients answering for themselves.

After quickly identifying social needs using this Screening Tool, health care or social service providers can then take the next step of connecting patients with community resources to address their patients’ unmet needs.

Implementing universal health-related social needs screening in clinical settings requires planning—aligning priorities, training staff, and developing customized screening protocols—so this guide also includes lessons based on the experiences of organizations participating in the Accountable Health Communities Model. The strategies shared in the guide are meant to inform effective universal screening in a wide range of clinical settings.

Promising practices for universal screening described in the guide

• Cultivate staff buy-in
• Tailor staffing models to site features
• Provide dedicated training on screening
• Use customized scripts to engage patients in screening
• Consider the timing, location, and process for screening to maximize patients’ participation
• Anticipate population-specific needs
• Train staff to manage privacy and address safety concerns
• Institute continuous quality improvement
• Prepare staff to respond to common questions