{"id":42902,"date":"2025-08-01T01:00:09","date_gmt":"2025-08-01T05:00:09","guid":{"rendered":"https:\/\/www.ncqa.org\/?page_id=42902"},"modified":"2025-09-29T12:11:56","modified_gmt":"2025-09-29T16:11:56","slug":"social-need-screening-and-intervention-sns-e","status":"publish","type":"page","link":"https:\/\/www.ncqa.org\/report-cards\/health-plans\/state-of-health-care-quality-report\/social-need-screening-and-intervention-sns-e\/","title":{"rendered":"Social Need Screening and Intervention (SNS-E)"},"content":{"rendered":"<p><span class=\"TextRun SCXW167364904 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW167364904 BCX4\">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 <\/span><span class=\"NormalTextRun SCXW167364904 BCX4\">30 days<\/span><span class=\"NormalTextRun SCXW167364904 BCX4\">.<\/span><\/span><span class=\"EOP SCXW167364904 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<h2>Why It Matters<\/h2>\n<p><span data-contrast=\"none\">Social determinants of health (SDOH) are defined as \u201cthe 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,\u201d including economic policies and systems, development agendas, social norms and political systems <sup><a href=\"#ref-1\">1<\/a><\/sup>. Social needs have considerable impact on health inequity and can include inadequate access to nutritious food, transportation barriers and inadequate or unstable housing <sup><a href=\"#ref-2\">2<\/a><\/sup> <sup><a href=\"#ref-3\">3<\/a><\/sup>.<\/span><\/p>\n<ul>\n<li><span data-contrast=\"none\">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 <sup><a href=\"#ref-4\">4<\/a><\/sup> <sup><a href=\"#ref-5\">5<\/a><\/sup>. This prevalence increases to 17.9% when there are children in the household <sup><a href=\"#ref-5\">5<\/a><\/sup>. 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 <sup><a href=\"#ref-6\">6<\/a><\/sup> <sup><a href=\"#ref-7\">7<\/a><\/sup>. 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 <sup><a href=\"#ref-8\">8<\/a><\/sup>.<\/span><\/li>\n<li><span data-contrast=\"none\">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 <sup><a href=\"#ref-9\">9<\/a><\/sup> <sup><a href=\"#ref-10\">10<\/a><\/sup>. As of January 2023, more than half a million Americans were experiencing homeless (653,104 people), a 12.1% increase from 2022 <sup><a href=\"#ref-11\">11<\/a><\/sup>. 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 <sup><a href=\"#ref-12\">12<\/a><\/sup>.<\/span><\/li>\n<li><span data-contrast=\"none\">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 <sup><a href=\"#ref-13\">13<\/a><\/sup>. Missed appointments, or \u201cno-shows,\u201d 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 <sup><a href=\"#ref-13\">13<\/a><\/sup>. 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 <sup><a href=\"#ref-14\">14<\/a><\/sup>. At the health plan level, CMS expanded the type of transportation benefits MA plans are able to provide\u2014including coverage for nonmedical transportation <sup><a href=\"#ref-15\">15<\/a><\/sup>.<\/span><\/li>\n<\/ul>\n<p><span data-contrast=\"none\">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 <sup><a href=\"#ref-16\">16<\/a><\/sup>, expanding SDOH screening tools and supporting payment reform policy that incentivize for SDOH screening and referral <sup><a href=\"#ref-2\">2<\/a><\/sup>. 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 <sup><a href=\"#ref-17\">17<\/a><\/sup>.<\/span><\/p>\n<h2><span data-teams=\"true\"> HISTORICAL RESULTS &#8211; NATIONAL AVERAGES<\/span><\/h2>\n<p><span data-teams=\"true\"><strong>Performance results for this measure are currently unavailable.<\/strong><\/span><\/p>\n<div class=\"footnotes\"><\/p>\n<h3>References<\/h3>\n<ol>\n<li id=\"ref-1\"><span data-contrast=\"none\">World Health Organization (WHO). 2020. Social Determinants of Health. <\/span><a href=\"http:\/\/www.who.int\/social_determinants\/en\/\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">http:\/\/www.who.int\/social_determinants\/en\/<\/span><\/span><\/a><span data-contrast=\"none\"> (May 6, 2020)<\/span><\/li>\n<li id=\"ref-2\"><span data-contrast=\"none\">American Medical Association (AMA). 2020. New AMA Policy Recognizes Racism as a Public Health Threat. <\/span><a href=\"https:\/\/www.ama-assn.org\/press-center\/press-releases\/new-ama-policy-recognizes-racism-public-health-threat\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.ama-assn.org\/press-center\/press-releases\/new-ama-policy-recognizes-racism-public-health-threat<\/span><\/span><\/a><\/li>\n<li id=\"ref-3\"><span data-contrast=\"none\">American Academy of Family Physicians (AAFP). 2019. Social Determinants of Health\u2014Guide to Social Needs Screening. Retrieved March 25, 2021, from <\/span><a href=\"https:\/\/www.aafp.org\/dam\/AAFP\/documents\/patient_care\/everyone_project\/hops19-physician-guide-sdoh.pdf\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.aafp.org\/dam\/AAFP\/documents\/patient_care\/everyone_project\/hops19-physician-guide-sdoh.pdf<\/span><\/span><\/a><\/li>\n<li id=\"ref-4\"><span data-contrast=\"none\">Rabbitt, M. P., Reed-Jones, M., Hales, L. J., &amp; Burke, M. P. 2024. \u201cHousehold food security in the United States in 2023 (Report No. ERR-337).\u201d U.S. Department of Agriculture, Economic Research Service. <\/span><a href=\"https:\/\/doi.org\/10.32747\/2024.8583175.ers\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.32747\/2024.8583175.ers<\/span><\/span><\/a><\/li>\n<li id=\"ref-5\"><span data-contrast=\"none\">US Department of Agriculture. November 29, 2023. Food Security and Nutrition Assistance. Economic Research Service. <\/span><a href=\"https:\/\/www.ers.usda.gov\/data-products\/ag-and-food-statistics-charting-the-essentials\/food-security-and-nutrition-assistance\/\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.ers.usda.gov\/data-products\/ag-and-food-statistics-charting-the-essentials\/food-security-and-nutrition-assistance\/<\/span><\/span><\/a><\/li>\n<li id=\"ref-6\"><span data-contrast=\"none\">Burke, M.P., L.H. Martini, E. \u00c7ay\u0131r, H.L. Hartline-Grafton, &amp; R.L. Meade. 2016. \u201cSeverity of Household Food Insecurity Is Positively Associated With Mental Disorders Among Children and Adolescents in the United States.\u201d The Journal of Nutrition, 146(10), 2019\u201326. <\/span><a href=\"https:\/\/doi.org\/10.3945\/jn.116.232298\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.3945\/jn.116.232298<\/span><\/span><\/a><\/li>\n<li id=\"ref-7\"><span data-contrast=\"none\">Gundersen, C., &amp; Ziliak, J. P. 2015. Food Insecurity and Health Outcomes. Health Affairs, 34(11), 1830\u20131839. <\/span><a href=\"https:\/\/doi.org\/10.1377\/hlthaff.2015.0645\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.1377\/hlthaff.2015.0645<\/span><\/span><\/a><\/li>\n<li id=\"ref-8\"><span data-contrast=\"none\">Feeding America. 2021. \u201cAddressing Food Insecurity in Health Care Settings.\u201d Hunger and Health. <\/span><a href=\"https:\/\/hungerandhealth.feedingamerica.org\/explore-our-work\/community-health-care-partnerships\/addressing-food-insecurity-in-health-care-settings\/\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/hungerandhealth.feedingamerica.org\/explore-our-work\/community-health-care-partnerships\/addressing-food-insecurity-in-health-care-settings\/<\/span><\/span><\/a><\/li>\n<li id=\"ref-9\"><span data-contrast=\"none\">Cox, R., S. Rodnyansky, B. Henwood, &amp; S.L. Wenzel. 2017. \u201cMeasuring Population Estimates of Housing Insecurity in the United States: A Comprehensive Approach.\u201d SSRN Electronic Journal. <\/span><a href=\"https:\/\/doi.org\/10.2139\/ssrn.3086243\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.2139\/ssrn.3086243<\/span><\/span><\/a><\/li>\n<li id=\"ref-10\"><span data-contrast=\"none\">Frederick, T.J., M. Chwalek, J. Hughes, J. Karabanow, &amp; S. Kidd. 2014. \u201cHow Stable Is Stable? Defining and Measuring Housing Stability: Defining and Measuring Housing Stability.\u201d Journal of Community Psychology 42(8), 964\u201379. <\/span><a href=\"https:\/\/doi.org\/10.1002\/jcop.21665\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.1002\/jcop.21665<\/span><\/span><\/a><\/li>\n<li id=\"ref-11\"><span data-contrast=\"none\">National Alliance to End Homelessness. 2013. State of Homelessness: 2023 Edition. <\/span><a href=\"https:\/\/endhomelessness.org\/homelessness-in-america\/homelessness-statistics\/state-of-homelessness\/#homelessness-in-2022\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/endhomelessness.org\/homelessness-in-america\/homelessness-statistics\/state-of-homelessness\/#homelessness-in-2022<\/span><\/span><\/a><\/li>\n<li id=\"ref-12\"><span data-contrast=\"none\">Bailey, P. 2020. Housing and Health Partners Can Work Together to Close the Housing Affordability Gap. Center on Budget and Policy Priorities. <\/span><a href=\"https:\/\/www.cbpp.org\/research\/housing\/housing-and-health-partners-can-work-together-to-close-the-housing-affordability\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.cbpp.org\/research\/housing\/housing-and-health-partners-can-work-together-to-close-the-housing-affordability<\/span><\/span><\/a><\/li>\n<li id=\"ref-13\"><span data-contrast=\"none\">AHA. 2017. Social Determinants of Health Series: Transportation and the Role of Hospitals. <\/span><a href=\"https:\/\/www.aha.org\/ahahret-guides\/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.aha.org\/ahahret-guides\/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals<\/span><\/span><\/a><\/li>\n<li id=\"ref-14\"><span data-contrast=\"none\">Silver, D., J. Blustein, &amp; B.C. Weitzman. 2012. \u201cTransportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites.\u201d Journal of Immigrant and Minority Health 14(2), 350\u20135.<\/span><\/li>\n<li id=\"ref-15\"><span data-contrast=\"none\">Kornfield, T., Kazan, M., Frieder, M., Duddy-Tenbrunsel, R., Donthi, S., &amp; Fix, A. 2020. Medicare Advantage Plans Offering Expanded Supplemental Benefits: A Look at Availability and Enrollment. <\/span><a href=\"https:\/\/www.commonwealthfund.org\/publications\/issue-briefs\/2021\/feb\/medicare-advantage-plans-supplemental-benefits\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.commonwealthfund.org\/publications\/issue-briefs\/2021\/feb\/medicare-advantage-plans-supplemental-benefits<\/span><\/span><\/a><\/li>\n<li id=\"ref-16\"><span data-contrast=\"none\">AHA. June 2019. Screening for Social Needs: Guiding Care Teams to Engage Patients. <\/span><a href=\"https:\/\/www.aha.org\/system\/files\/media\/file\/2019\/09\/screening-for-social-needs-tool-value-initiative-rev-9-26-2019.pdf\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/www.aha.org\/system\/files\/media\/file\/2019\/09\/screening-for-social-needs-tool-value-initiative-rev-9-26-2019.pdf<\/span><\/span><\/a><\/li>\n<li id=\"ref-17\"><span data-contrast=\"none\">American Academy of Pediatrics. 2025. Social Drivers of Health: Implications for Clinical Practice. AAP.Org. <\/span><a href=\"https:\/\/doi.org\/10.1542\/9781610027922\"><span data-contrast=\"none\"><span data-ccp-charstyle=\"Hyperlink\">https:\/\/doi.org\/10.1542\/9781610027922<\/span><\/span><\/a><\/li>\n<\/ol>\n<p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":45,"featured_media":0,"parent":733,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page.php","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-42902","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - 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