HEDIS® Tip Sheet

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

Line of business: BlueAlliance (Commercial) & BlueAlliance Care+ (Medicaid)

Measure Description

Percentage of members who were screened, using prespecified instruments, at least once during the measurement period for unmet food housing and transportation needs, and received a corresponding intervention if they screened positive.  

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.

Compliance

Food Screening: Members with a documented result for food insecurity screening performed between January 1 and December 1 of the measurement period.  
Food Intervention: Members who received a corresponding intervention within 30 days (1 month) of screening positive for food insecurity.

Housing Screening: Members with a documented results for housing instability, homelessness or housing inadequacy screening performed between January 1 and December 1 of the measurement period.
Housing Intervention: Members who received a corresponding intervention within 30 days (1 month) for housing instability, homelessness or housing inadequacy.

Transportation Screening: Members with a documented result for transportation insecurity performed between January 1 and December 1 of the measurement period.  
Transportation Intervention: Members who received a corresponding intervention within 30 days (1 month) of screening positive for transportation insecurity.

Population

Members any age enrolled at the start of the measurement period who meet criteria for participation. 

Measurement Period

January 1 – December 31

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. Rates are reported in three age stratifications and a total rate.
    • < 17 years
    • 18-64 years
    • 65+ years
    • Total Rate
  • Age is as of the start of the measurement period. 


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



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



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



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.
    • Example:  A positive food insecurity screen finding must be met by a food insecurity intervention.
    • For Housing Interventions, the intervention must correspond to the type of housing need identified (housing instability, homelessness, or housing inadequacy).
  • May include any of the following categories:
    • Adjustment
    • Assistance
    • Coordination
    • Counseling
    • Education
    • Evaluation of eligibility
    • Evaluation/Assessment
    • 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

  • 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 on screening and documenting patients’ social needs.
  • Document the date of the screening and corresponding intervention if a positive screen was identified.

Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

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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