Social Need Screening and Intervention (SNS-E)

The percentage of persons who were screened using prespecified instruments, or assessed by a provider, for unmet food, housing and transportation needs at least once during the measurement period, and the percentage of persons with a positive screen or identified need for food, housing or transportation who received an intervention corresponding to the positive screen or identified need within 30 days. 

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 13.5% of American households during 2023, a statistically significant increase from 12.8% in 2022 4 5. This prevalence increases to 17.9% 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 2023, more than half a million Americans were experiencing homeless (653,104 people), a 12.1% increase from 2022 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 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.

HISTORICAL RESULTS – NATIONAL AVERAGES

Performance results for this measure are currently unavailable.

References

  1. World Health Organization (WHO). 2020. Social Determinants of Health. http://www.who.int/social_determinants/en/ (May 6, 2020)
  2. American Medical Association (AMA). 2020. New AMA Policy Recognizes Racism as a Public Health Threat. https://www.ama-assn.org/press-center/press-releases/new-ama-policy-recognizes-racism-public-health-threat
  3. American Academy of Family Physicians (AAFP). 2019. Social Determinants of Health—Guide to Social Needs Screening. Retrieved March 25, 2021, from https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-guide-sdoh.pdf
  4. Rabbitt, M. P., Reed-Jones, M., Hales, L. J., & Burke, M. P. 2024. “Household food security in the United States in 2023 (Report No. ERR-337).” U.S. Department of Agriculture, Economic Research Service. https://doi.org/10.32747/2024.8583175.ers
  5. US Department of Agriculture. November 29, 2023. Food Security and Nutrition Assistance. Economic Research Service. https://www.ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/food-security-and-nutrition-assistance/
  6. Burke, M.P., L.H. Martini, E. Çayır, H.L. Hartline-Grafton, & R.L. Meade. 2016. “Severity of Household Food Insecurity Is Positively Associated With Mental Disorders Among Children and Adolescents in the United States.” The Journal of Nutrition, 146(10), 2019–26. https://doi.org/10.3945/jn.116.232298
  7. Gundersen, C., & Ziliak, J. P. 2015. Food Insecurity and Health Outcomes. Health Affairs, 34(11), 1830–1839. https://doi.org/10.1377/hlthaff.2015.0645
  8. Feeding America. 2021. “Addressing Food Insecurity in Health Care Settings.” Hunger and Health. https://hungerandhealth.feedingamerica.org/explore-our-work/community-health-care-partnerships/addressing-food-insecurity-in-health-care-settings/
  9. Cox, R., S. Rodnyansky, B. Henwood, & S.L. Wenzel. 2017. “Measuring Population Estimates of Housing Insecurity in the United States: A Comprehensive Approach.” SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3086243
  10. Frederick, T.J., M. Chwalek, J. Hughes, J. Karabanow, & S. Kidd. 2014. “How Stable Is Stable? Defining and Measuring Housing Stability: Defining and Measuring Housing Stability.” Journal of Community Psychology 42(8), 964–79. https://doi.org/10.1002/jcop.21665
  11. National Alliance to End Homelessness. 2013. State of Homelessness: 2023 Edition. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/#homelessness-in-2022
  12. Bailey, P. 2020. Housing and Health Partners Can Work Together to Close the Housing Affordability Gap. Center on Budget and Policy Priorities. https://www.cbpp.org/research/housing/housing-and-health-partners-can-work-together-to-close-the-housing-affordability
  13. AHA. 2017. Social Determinants of Health Series: Transportation and the Role of Hospitals. https://www.aha.org/ahahret-guides/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals
  14. Silver, D., J. Blustein, & B.C. Weitzman. 2012. “Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites.” Journal of Immigrant and Minority Health 14(2), 350–5.
  15. Kornfield, T., Kazan, M., Frieder, M., Duddy-Tenbrunsel, R., Donthi, S., & Fix, A. 2020. Medicare Advantage Plans Offering Expanded Supplemental Benefits: A Look at Availability and Enrollment. https://www.commonwealthfund.org/publications/issue-briefs/2021/feb/medicare-advantage-plans-supplemental-benefits
  16. AHA. June 2019. Screening for Social Needs: Guiding Care Teams to Engage Patients. https://www.aha.org/system/files/media/file/2019/09/screening-for-social-needs-tool-value-initiative-rev-9-26-2019.pdf
  17. American Academy of Pediatrics. 2025. Social Drivers of Health: Implications for Clinical Practice. AAP.Org. https://doi.org/10.1542/9781610027922

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