The Hospital CMS Survey Requirement Starts January 1, 2024

Finding information about the Social Drivers of Health (SDOH) measures has been easy. However, it’s been difficult to find the details of the CMS Hospital Inpatient SDOH Measures.

The most useful document that we’ve seen from CMS about Hospital Inpatient SDOH screening is the Frequently Asked Questions: Social Drivers of Health (SDOH) Measures August 2023. This document outlines what needs to be reported and how to calculate the measures, but unfortunately stops short of answering all relevant questions. https://qualitynet.cms.gov/inpatient/iqr/measures#tab2

Question 2 in this document defines the numerator and denominator for screening and for the screen positive rate for SDOH.

Question 4 defines in more detail how to calculate the screen positive rate:

Patients screened for less than all five SDOH areas are not included in the “screened” denominators. If a patient has more than one inpatient admission during the reporting period, the most recent survey result should be submitted. Providing a specific definition for to sort out multiple admissions and multiple surveys is useful.

Now things get a little murkier.

The AHC HRSN Screening Tool

CMS reiterates that there are currently no recommended value sets and no specific questions for each HRSN. CMS has created a screening tool, the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool but is not requiring its use. https://www.cms.gov/priorities/innovation/files/worksheets/ahcm-screeningtool.pdf 

However, in the FAQ document from August 2023, CMS says that the first ten questions of the AHC HRSN Tool meet the requirements for the five measures.

But what if someone answers the first question from the AHC HRSN Tool about housing saying that they have a place to live today but are worried about losing it in the future and then doesn’t answer the second housing question about problems like mold, pests, etc. Do they meet the screening requirement for housing insecurity or not? There is no guidance on this in the FAQ document.

Later in the document, CMS sidesteps the first part of question 20: is it acceptable to reduce the number of questions in the validated tool to collect data, as long as you ask one in each of 5 categories?  The unhelpful answer--to report on this measure to CMS, hospitals need to provide: (1) the number of inpatients admitted to the hospital who are 18 years or older at time of admission and who are screened for all 5 of the five HRSNs: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

What about Z codes?

Putting aside for the moment the question of why Z codes weren’t used for SDOH reporting in the first place, the August 2023 FAQ document says the following about their use:

“If the use of this code means that the hospital has screened for that given HRSN and that patient has screened positive for it, hospitals could use Z codes in this way.”

While this may seem to require a survey question, this could be interpreted as looking for the documentation for a code in the EHR, which is true of any code, not just Z codes.  The statement implies a survey source, but the following statement seems to contradict it:

“Survey data can be sourced from anywhere in the EHR”

At the end of the FAQ document, CMS states:

“If information on food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety are collected elsewhere in the EHR during the admission, that data can be used to satisfy the screening requirement of this measure.”

Therefore, documentation in notes can serve as survey responses. This is especially important for sensitive topics. We know that certain concerns, like domestic violence, are voiced only behind closed doors with a trusted provider, not to a staff person never seen before, or on a clipboard, a tablet or a kiosk.

We don’t make the rules

We can’t tell you what to do with the AHC HRSN 10 questions to 5 items conundrum. But we believe that multiple data sources provide a more complete picture of a patient’s SDOH profile. We use data extracted from text notes as well other standard SDOH data to augment survey data for a more complete perspective of your patients and their needs. Actionable data is key to changing SDOH and to meeting the CMS requirements.

What do you think?  Join us on LinkedIn and join the conversation.

Hospital Partnership Spotlight: RIP Medical Debt

While the United States spends a higher percentage of its GDP on healthcare than any other high-income nation, this expenditure hasn't translated into fair access, efficient systems, or improved health outcomes. In fact, the U.S. spends more but still underperforms in comparison to comparable countries’ health care systems. Lack of universal healthcare coverage still leaves around 10% of Americans uninsured, increasing their vulnerability in time of need. Americans also delay needed medical care due to costs and growing debt, impacting their overall quality of life and contributing to poor health outcomes. 

“We have significant disparities in how people access healthcare, preventative care and how basic socio-economic needs are met in the US,” says Anita Karcz, MD, IHM’s Chief Medical Officer. These disparities are collectively termed social determinants of health, which are the factors that affect an individual’s health status. Issues such as food insecurity and limited access to healthcare create barriers that perpetuate health inequalities. Addressing these health determinants is pivotal for improving overall health outcomes while lowering the total cost of healthcare.

Healthy People 2030, an HHS website, provides a useful overview of the social determinants of health, organized into five domains:

• Economic Stability

• Education Access and Quality

• Healthcare Access and Quality

• Neighborhood and Built Environment

• Social and Community Context

Medical debt, an often-overlooked factor in the healthcare access and quality domain, has profound consequences. People burdened with medical debt are more likely to defer necessary medical care, exacerbating existing health conditions. This is not just a problem of the uninsured. Even insured individuals struggle with medical debt due to high insurance deductibles. 

Founded in 2014, RIP Medical Debt, a not-for-profit organization, addresses the problem of medical debt with a unique model. Partnering with hospitals, RIP Medical Debt identifies individuals in need, targeting those whose debt is more than 5% of their income or whose income is under 400% of federal poverty guidelines. Then they leverage donor contributions to purchase the medical debt from hospitals and write letters to the individuals whose debt has been erased.  To date, RIP Medical Debt has relieved over $10 billion in medical debt for over 6.7 million individuals and families. As people's financial burdens are reduced, they are more likely to seek timely medical care and improve their long-term health outlook. 

By collaborating with RIP Medical Debt, hospitals contribute to improved community well-being beyond direct medical treatment.  RIP Medical Debt is an additional resource to hospitals to help figure out which eligible patients are unaware of existing hospital financial assistance programs.  

“Hospitals have limited resources … and are generally very committed to the health of their community... and want to make sure those folks do not have a delay in care because of those past debts; so, by working with us, we pay the hospital for their debts…” says Ruth Lande, Vice President of Hospital Relations at RIP Medical Debt.

Addressing medical debt also enables hospitals to indirectly contribute to better long-term health outcomes since individuals who receive assistance are more likely to engage in preventive care and manage their health conditions more effectively.

While there is still a long journey ahead to address systemic healthcare issues and ensure that every individual can access the care they deserve regardless of their circumstances, RIP Medical Debt is an example of an organization making progress against a seemingly impenetrable barrier to improved healthcare for all. 

Click here to watch the webinar replay of Anita’s conversation with Ruth.  And, to learn more about RIP Medical Debt, visit their website.

Health Equity and Hospitals: The Gap Between Regulations and Reality

Social determinants of health (SDOH) have long been known to have a greater effect on a person’s health than their medical care.

Since 2010, the Affordable Care Act has required not-for-profit hospitals to conduct a community health needs assessment (CHNA) once every three years to develop strategies to meet identified needs. The CHNA imposed structure on what many hospitals were already doing: addressing needs within their community by partnering with like-minded organizations.

More recently, The Joint Commission (TJC) and The Centers for Medicare & Medicaid Services (CMS) have set forth hospital requirements for addressing health equity. TJC has several requirements for hospitals including data for use in stratification of patient populations: age, gender, preferred language, race, and ethnicity. These data are already available in structured data in the electronic health record (EHR), though perhaps requiring staff training to improve data capture accuracy for these elements. Additional data elements to be gathered include sexual orientation, gender identity and disabilities.

The Joint Commission also states that the organization should assess the patient’s health-related social needs (HRSN) and provide information about community resources and support services. While they state that the organization can determine which health-related social needs to include in the patient assessment, they provide the following examples:

• Access to transportation

• Difficulty paying for prescriptions or medical bills

• Education and literacy

• Food insecurity

• Housing insecurity

They also note that health-related social needs may be identified for a representative sample of the organization’s patients or for all the organization’s patients, and for other indicators.

CMS’s data gathering requirements are much more specific. Reporting is voluntary in 2023 and becomes mandatory in 2024, with standardized individual-level demographic and SDOH data, including race, ethnicity, language, gender identity, gender, sexual orientation, disability status, and SDOH. The SDOH require surveying inpatients for five factors: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. Asking about SDOH, gender identity and sexual orientation can be sensitive, particularly in smaller communities.

“We’re a small community. Even though staff are bound by HIPAA and professional confidentiality, patients won’t feel comfortable talking about their sexual orientation or housing insecurity with a staff member. We’ll get “check the box” answers on those, for sure.”

Director of Quality

CMS is not requiring a particular survey tool but has developed a Health-Related Social Needs Screening Tool (HRSN). This tool addresses the five required SDOH measures. In the final version, CMS also included questions in 8 supplemental domains:

• Financial strain

• Employment

• Family and community support

• Education

• Physical activity

• Substance use

• Mental health

• Disabilities

The questions in the HRSN survey about housing insecurity raise the question of what can be done by a hospital once this information is uncovered. Referral to community agencies is advised.

1. What is your living situation today?

• I have a steady place to live

• I have a place to live today, but I am worried about losing it in the future

• I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

2. Think about the place you live. Do you have problems with any of the following?

CHOOSE ALL THAT APPLY

• Pests such as bugs, ants, or mice

• Mold

• Lead paint or pipes

• Lack of heat

• Oven or stove not working

• Smoke detectors missing or not working

• Water leaks

• None of the above

“We just don’t have enough hours in the day for our social workers or nurses to do this screening in the way that it needs to be done. And when we ask what we can, what do we do about their answers? Referring people for help sounds simple, but our referral network can’t accommodate all of these people and their very real problems.”

Hospital VP Quality

Patients can be provided with a paper or electronic form to complete before a visit so that the practitioner can later review during the visit. Since many hospital admissions are urgent or emergent, this will not be a viable approach for many patients who may be too ill to participate. While a significant other could complete the form, they won’t admit that they’ve been ignoring an elderly parent or abusing their intimate partner. Also, many patients are reluctant to answer sensitive questions, even on a faceless form.

Alternatively, a practitioner can screen in-person or by phone in elective situations. However, this is not an exercise that can be delegated to the untrained if the goal is to get honest answers to the questions from the patient.

Effective screening is clearly more complicated than asking patients questions. At IHM, we believe that census tract data both at the community and patient level combined with EHR data can serve as a “better together” strategy for evaluating patient survey data. With more data, clinical and community program outcomes can be measured. For example, what is the effect on Hemoglobin A1C and body mass index (BMI) in patient populations from communities with weight control/activity programs?

Hospitals can’t offer every service needed in their communities, but by leading and participating in coalitions with other local organizations and focusing on critical community needs, much good work is possible. Most importantly, effects can be measured, justifying program expansion and grant funding.

Additional resources:

The American Hospital Association (AHA) has developed specific recommendations for data collection, leadership and governance and community partnerships to further cultural competency and health equity.

Nationally standardized and stakeholder-driven, the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) is designed to equip healthcare and their community partners to better understand and act on individuals’ social drivers of health (SDOH). Available in 25 languages.

About the Institute for Health Metrics (IHM)

For over a decade, the Institute for Health Metrics (IHM) has been an innovator in using real-world data (RWD) for healthcare research, creating the first SaaS Meaningful Use reporting system as well as insightsDB™, a purpose built, HIPAA compliant, cloud data platform. IHM data- including clinical detail, unstructured notes, and Social Determinants of Health for studying outcomes and comparative effectiveness- represents community hospitals from across the United States, a unique population often under-represented in medical literature and clinical trials. IHM enables healthcare organizations to create better outcomes through the use of better data. For more information, visit www.healthmetrics.org or contact john.volpe@healthmetrics.org.

Hospital Regulatory Requirements to Address Health Equity

While the healthcare industry’s primary focus is the treatment of injury or illness, achieving health equity is much more complicated. Effective action requires community coalitions with employers, public health agencies, community, faith-based organizations, and elected officials.  Fundamental to success is an understanding of the underlying attributes of a population group, called the Social Determinants of Health (SDOH).

Since 2010, not-for-profit hospitals have been required by the Affordable Care Act to conduct a community health needs assessment (CHNA) once every three years and develop strategies to meet needs identified by the CHNA. 

The Center for Disease Control (CDC) defines a community health needs assessment as: 

• the process of community engagement

• collection, analysis, and interpretation of data on health outcomes and health determinants

• identification of health disparities

• identification of resources that can be used to address priority needs

The Joint Commission (TJC) published new health equity requirements effective January 1, 2023, for ambulatory health care, behavioral health care and human services, critical access hospitals, and hospital accreditation programs.  The TJC requires such organizations to:

1. Designate an individual(s) to lead activities to reduce health care disparities for the organization’s patients

2. Assess the patient’s health-related social needs and provide information about community resources and support services

3. Identify health care disparities in their patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients

4. Act when the organization does not achieve or sustain the goal(s) in its action plan to reduce health care disparities

5. Monitor effectiveness of its action plan to reduce health care disparities in its patient population

6. Inform key stakeholders, at least annually, including leaders, licensed practitioners, and staff, about organizational progress to reduce identified health care disparities

Achieving TJC requirements requires actionable data in support of a structured process for identifying health disparities, and developing programs to address them, as well as measuring results to inform future initiatives. Other accrediting organizations are adopting similar initiatives.

The Centers for Medicare & Medicaid Services (CMS) has published a ten-year Framework for Health Equity Priorities. In a specific rule tied to hospital reimbursement, CMS has added three health equity focused measures to the Hospital Inpatient Quality Reporting (IQR) Program. For acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) that successfully participate in the IQR Program and are meaningful electronic health record users, this final rule will result in an increase in payment rates of 4.3%. 

The first new IQR measure assesses a hospital’s commitment to establishing a culture of equity and delivering more equitable health care by capturing activities across five key domains, including strategic planning, data collection, data analysis, quality improvement, and leadership engagement. This Hospital Commitment to Health Equity measure begins with the 2023 reporting period.

The second and third measures address screening and identification of patients’ health-related social needs. The second measure is the percent of inpatients screened for these five SDOH needs, and the third measure is the percent of patients screened who had an SDOH risk factor identified.

CMS has designated five social needs for screening and identification: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. CMS notes in their final rule that certain ICD10 Z codes (Z55 - Z65 - Persons with potential health hazards related to socioeconomic and psychosocial circumstances) are not well utilized by hospitals for a variety of reasons to identify SDOH in their patients. However, CMS chose not to require use of these codes for SDOH measurement but is requiring more detailed screening measures.

Screening for Social Drivers of Health (measure 2) and Screen Positive Rate for Social Drivers of Health (measure 3) begin with voluntary reporting in 2023 with mandatory reporting required in 2024.

In addition, CMS has created a new designation to identify “Birthing-Friendly” hospitals and additional quality measure reporting to drive improvements in maternal health outcomes.

This regulatory spotlight on health equity is well intentioned. However, the ultimate question is: will identifying social determinants of health and referrals to services reduce health disparities?

Collecting SDOH

“Within the past 12 months, how often did you worry that your food would run out before you got money to buy more?”

Recently I’ve been part of conversations about asking social determinants of health (SDOH) related questions, like this food insecurity example, to patients as part of a provider visit.  Screening surveys would seem the best way to pinpoint social needs in patients that come in for treatment.  However, it isn’t an easy task, for many reasons, and even if you could survey every patient- and get accurate answers- a group of patients don’t necessarily provide insight into the entire community being served.

These conversations reminded me of my recent annual primary care visit at one of Boston’s major medical centers. First, I was asked a couple of screening questions by the woman who checked my insurance status. Then I was then asked a couple more questions by the receptionist in my PCP’s office. And when I made it to the medical assistant who checked my weight and vital signs, she handed me a list of questions with verbal instructions to tell her if my answer was yes to any of them and went off to do something. I was in an open area, with another medical assistant sitting next to me working on a computer. The first question was “Have you had thoughts of suicide?” Even if I had, would I be likely to answer candidly in that setting? If I was asked whether I had enough money to buy food, would I answer truthfully?

Sensitivity as to how and when to ask patients such questions is critical. This is true of so many things which are often best addressed in privacy with the provider.  However, the provider is often overloaded, so these questions are often delegated to others. What I’ve described from my personal experience, and what I have heard from the experiences of others, will get you answers, but they could be useless.

Beyond the interpersonal issues, what questions do you ask? There are already many required questions for various quality programs. How do you prioritize? There are many SDOH variables and no organization can address them all.

At IHM, we think about the sources of SDOH data in three categories:

We’ve already discussed the option of acquiring data directly from patient surveys.

EHR data can be a good source of SDOH data but the information is often buried in free text notes and not easily accessible for evaluating individual patients or a patient population.

Government data can provide broad insights into SDOH both by census tract linked to patient address and by catchment area. This data is not easy to work with, but IHM has made it accessible and understandable to our member hospitals, including the IHM SDOH Index, a single index derived from multiple SDOH variables to facilitate analytics.

Our premise is that starting with government data at both a patient and a community level enables hospitals to target priority areas and then gather additional information by focused patient surveys. Community data will also inform hospital community needs assessments and prioritize community initiatives.

What are your personal or organizational experiences with social determinants of health data collection?  I’d be glad to hear your thoughts and experiences.

Anita Karcz MD MBA

Chief Medical Officer and Co-Founder

anita@healthmetrics.org

References

• ‘The Health Leads Screening Toolkit’. Health Leads, https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/.

• Center for Medicare and Medicaid Innovation. The Accountable Health Communities Health-Related Social Needs Screening Tool. Center for Medicare and Medicaid Innovation, https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.

• ‘Homepage’. PRAPARE, https://prapare.org/.