HEDIS® Tip Sheet

Social Needs Screening and Follow-Up (SNS-E)

Measure Description

Percentage of members who were screened, using a standardized screening  tool, at least once during the measurement year for unmet food, housing, and transportation needs, and received a corresponding intervention within 30 days if they screened positive.

Compliance

Food Screening: The percentage of members who were screened for food insecurity.
Food Intervention: The percentage of members who received a corresponding intervention within 30 days (1 month) of screening positive for food insecurity.

Housing Screening: The percentage of members who were screened for housing instability, homelessness or housing inadequacy.
Housing Intervention: The percentage of members who received a corresponding intervention within 30 days (1 month) for housing instability, homelessness or housing inadequacy.

Transportation Screening: The percentage of members who were screened for transportation insecurity.
Transportation Intervention: The percentage of members who received a corresponding intervention within 30 days (1 month) of screening positive for transportation insecurity.

Defintions

Food insecurity: Uncertain, limited or unstable access to food that is adequate in quantity and in nutritional quality; culturally acceptable; safe; and acquired in socially acceptable ways.

Housing instability: Currently consistently housed but experiencing any of the following circumstances in the past 365 days: being behind on rent or mortgage, multiple moves, cost burden or risk of eviction.

Homelessness: Currently living in an environment that is not meant for permanent human habitation (e.g., car, park, sidewalk, abandoned building, on the street); not having a consistent place to sleep at night; or because of economic difficulties, currently living in a shelter, motel, temporary or transitional living situation.

Housing inadequacy: Housing does not meet habitability standards.

Transportation insecurity: Uncertain, limited or no access to safe, reliable, accessible, affordable and socially acceptable transportation infrastructure and modalities necessary for maintaining one’s health, well-being or livelihood.

Notes

  • Data for screening will come from supplemental data sources.

Screening Tools

Eligible screening instruments:

1Proprietary; may be cost or licensing requirement associated with use.

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Interventions

  • Interventions must correspond to the positive finding on the administered screening on or up to 30 days after the date of the first positive screening during the measurement period. For example, 
    • A positive food insecurity screen finding must be met by a food insecurity intervention,
    • A positive housing instability or homelessness need finding must be met by a housing instability or homelessness intervention., etc.
  • Interventions may include assistance, counseling, coordination, education, evaluation of eligibility, provision, or referral.
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Exclusions

  • Members in hospice during the measurement year.
  • Members who die any time during the measurement period. 
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Best Practices

  • Ask patients about their social needs in a private setting with enough time and space for discussion. Some patients may need prompting to talk with their provider about nonmedical needs.
  • Screen patients for food insecurity, housing instability, homelessness, housing inadequacy, and transportation insecurity using an eligible screening instrument at a minimum annually.
  • Educate patients on the purpose of social needs screening and offer support and resources as needed.
  • Make referrals to community resources as appropriate.
  • Utilize EMR reporting and patient flags for those in need of screening.
  • Schedule an intervention at the time a positive screen is identified.
  • Educate staff on the importance of screening and documenting patients’ social needs.
  • Document the date of the screening and corresponding intervention if a positive screen was identified.

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

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Updated 8/28/2026