The AHC Health-Related Social Needs Screening Tool

The Accountable Health Communities Health-Related Social Needs Screening Tool
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Zipcode
Date of survey

MonthDayYear
Date
When was your last Emergency room visit?
What’s the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool?

We at the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) created the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool for use in the AHC Model. We’re testing to see if systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries can impact their overall health care costs and improve their health outcomes.

Why is the AHC HRSN Screening Tool Important?

Growing evidence suggests that addressing unmet HRSNs—such as homelessness, hunger, and exposure to violence—can mitigate their negative effects on health. Much like clinical assessment tools, providers can use the results from the HRSN Screening Tool to inform patients' treatment plans and make appropriate referrals to community services.

What Does the AHC HRSN Screening Tool Mean for Me?

Screening for HRSNs is not yet a standard clinical practice. However, we are working to make the AHC HRSN Screening Tool a standard screening across all the communities in the AHC Model. This tool is shared for awareness and to promote its use.

What’s in the AHC HRSN Screening Tool?

In a National Academy of Medicine discussion paper, we introduced the 10-item HRSN Screening Tool. This tool helps providers assess patients’ needs across five core domains that community services can address:
- Housing instability
- Food insecurity
- Transportation problems
- Utility help needs
- Interpersonal safety
In the final version below, we made small revisions to the original 10 questions based on cognitive testing we did since we shared the first version. In the final version, we also included questions in 8 supplemental domains that we haven’t shared before:
- Financial strain
- Employment
- Family and community support
- Education
- Physical activity
- Substance use
- Mental health
- Disabilities
Who should use the AHC HRSN Screening Tool?

The questions in the AHC HRSN Screening Tool are meant to be used for individual respondents who answer the questions themselves. A parent or caregiver can answer for an individual too, if that makes more sense. Clinicians and their staff can easily use this short tool as part of their busy clinical workflows with people of all different ages, backgrounds, and settings.

In the next 5 years, hundreds of participating clinical delivery sites across the 32 AHCs will screen over 7 million Medicare and Medicaid beneficiaries using the 10 core domain questions. The AHCs can also choose to add any of the supplemental domain questions into their standard screening processes.

Who made the AHC HRSN Screening Tool?

We made this tool with a panel of experts from around the country, including:
- Tool developers
- Public health and clinical researchers
- Clinicians
- Population health and health systems executives
- Community-based organization leaders
- Federal partners
We got permission from the original authors of the questions to use, copy, modify, publish, and distribute the questions for the AHC Model and our use only. Based on feedback from the original question authors, CMS has created this table to specify the citation and notification process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.
AHC HRSN Screening Tool Core Questions
If someone chooses the underlined answers, they might have an unmet health-related social need.

Living Situation
1. What is your living situation today?

I have a steady place to liveI have a place to live today, but I am worried about losing it in the futureI do not have a steady place to live (I am temporarily staying with others, in a hotel, in ashelter, living outside on the stre
1. How do you get to your medical visits?

Public TransportationMy own transportationRely of friends and familyI have no transportation
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 miceMoldLead paint or pipesLack of heatOven or stove not workingSmoke detectors missing or not workingWater leaksNone of the above
Food
Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.
3. Within the past 12 months, you worried that your food would run out before you gotmoney to buy more.

Often trueSometimes trueNever true
4. Within the past 12 months, the food you bought just didn't last and you didn't havemoney to get more.

Often trueSometimes trueNever true
Transportation
5. In the past 12 months, has lack of reliable transportation kept you from medicalappointments, meetings, work or from getting things needed for daily living?

YesNo
Utilities
6. In the past 12 months has the electric, gas, oil, or water company threatened to shutoff services in your home?

YesNoAlready shut off
Safety
Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.
7. How often does anyone, including family and friends, physically hurt you?

Never (1)Rarely (2)Sometimes (3)Fairly often (4)Frequently (5)
When was the last ER Visit
8. How often does anyone, including family and friends, insult or talk down to you?

Never (1)Rarely (2)Sometimes (3)Fairly often (4)Frequently (5)
9. How often does anyone, including family and friends, threaten you with harm?

Never (1)Rarely (2)Sometimes (3)Fairly often (4)Frequently (5)
10. How often does anyone, including family and friends, scream or curse at you?

Never (1)Rarely (2)Sometimes (3)Fairly often (4)Frequently (5)
A score of 11 or more when the numerical values for answers to questions 7-10 are added shows that the person might not be safe.
AHC HRSN Screening Tool Supplemental Questions

Financial Strain
11. How hard is it for you to pay for the very basics like food, housing, medical care, andheating? Would you say it is:

Very hardSomewhat hardNot hard at all
Employment
12. Do you want help finding or keeping work or a job?

Yes, help finding workYes, help keeping workI do not need or want help
Family and Community Support
13. If for any reason you need help with day-to-day activities such as bathing, preparingmeals, shopping, managing finances, etc., do you get the help you need?

I don’t need any helpI get all the help I needI could use a little more helpI need a lot more help
14. How often do you feel lonely or isolated from those around you?

NeverRarelySometimesOftenAlways
Education
15. Do you speak a language other than English at home?

YesNo
16. Do you want help with school or training? For example, starting or completing jobtraining or getting a high school diploma, GED or equivalent.

YesNo
Physical Activity
17. In the last 30 days, other than the activities you did for work, on average, how manydays per week did you engage in moderate exercise (like walking fast, running,jogging, dancing, swimming, biking, or other similar activities)?

1234567
18. On average, how many minutes did you usually spend exercising at this level on oneof those days?

010203040506090120150 or greater
Follow these 2 steps to decide if the person has a physical activity need:

1. Calculate [“number of days” selected] x [“number of minutes” selected] = [number of minutes of exercise per week]
2. Apply the right age threshold:
• Under 6 years old: You can’t find the physical activity need for people under 6.
• Age 6 to 17: Less than an average of 60 minutes a day shows an HRSN.
• Age 18 or older: Less than 150 minutes a week shows an HRSN.
Substance Use
The next questions relate to your experience with alcohol, cigarettes, and other drugs.
Some of the substances are prescribed by a doctor (like pain medications), but only
count those if you have taken them for reasons or in doses other than prescribed. One
question is about illicit or illegal drug use, but we only ask in order to identify community
services that may be available to help you.
19. How many times in the past 12 months have you had 5 or more drinks in a day(males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5ounces of wine, or 1.5 ounces of 80-proof spirits.

NeverOnce or TwiceMonthlyWeeklyDaily or Almost Daily
20. How many times in the past 12 months have you used tobacco products (likecigarettes, cigars, snuff, chew, electronic cigarettes)?

NeverOnce or TwiceMonthlyWeeklyDaily or Almost Daily
21. How many times in the past year have you used prescription drugs for non-medicalreasons?

NeverOnce or TwiceMonthlyWeeklyDaily or Almost Daily
22. How many times in the past year have you used illegal drugs?

NeverOnce or TwiceMonthlyWeeklyDaily or Almost Daily
Mental Health
23. Over the past 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things?

Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)
b. Feeling down, depressed, or hopeless?

Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)
If you get 3 or more when you add the answers to questions 23a and 23b the person may have a mental health need.
24. Stress means a situation in which a person feels tense, restless, nervous, or anxious,or is unable to sleep at night because his or her mind is troubled all the time. Do youfeel this kind of stress these days?1

Not at allA little bitQuite a bitVery much
Disabilities
25. Because of a physical, mental, or emotional condition, do you have serious difficultyconcentrating, remembering, or making decisions? (5 years old or older)

YesNo
26. Because of a physical, mental, or emotional condition, do you have difficulty doingerrands alone such as visiting a doctor's office or shopping? (15 years old or older)

YesNo
When is the next appointment date
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The Accountable Health Communities Health-Related Social Needs Screening Tool