Screening for Health-Related Social Needs (HRSN)  

A hope of reducing healthcare costs and improving overall health for EOM and others   

Health Outcomes and Social Context 

In a comprehensive healthcare system, assessments and interventions must consider all factors that contribute to a person’s health. This means conducting well-rounded assessments that consider health-related social needs (HRSN) like housing instability, food insecurity, transportation, and other factors that can lead to poor health outcomes for people. 

Social factors impact a wide range of health outcomes. Researching how to address them is the first step in creating solutions.  

Health-related social needs and social determinants of health (SDOH) are two components to consider when delving into an individual’s social context. While SDOH and HRSN are both crucial to consider in healthcare services, they differ slightly.  

Social determinants of health are factors associated with the environments in which people live. These factors are heavily centered around the built environment, economic stability, and community.  

Health-related social needs impact how and to what degree a person can maintain their health (CMS, 2022). They are the unmet needs that may happen because of certain social determinants of health. While our understanding of social determinants of health has greatly expanded in recent years, health-related social needs remain less addressed. 

 Both social determinants of health and health-related social needs have profound impacts on a person’s health and how they are able to receive care (Billioux et al, 2017). Identifying unmet health-related social needs presents an opportunity to build dynamic solutions that align with people’s daily life. 

A muti-study review found that addressing social needs such as nutrition, housing instability, transportation, and other factors has made a positive impact in driving healthcare utilization and overall health outcomes (McCarthy et al, 2022). Another result was cost reduction. Though the importance of acknowledging health-related social needs is evident, there are few tools to address these unmet needs. 

A New Tool Improves Screening for Unmet Social Needs 

To better assess unmet health-related social needs in clinical settings, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) developed the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. This 10-item screening tool is designed to improve health outcomes via treatment and resource referrals for patients, aligning with the principles of the Accountable Health Communities Model. Assessing the main domains of housing instability, food insecurity, transportation problems, utility help needs, and interpersonal needs allows for insight on the community services and resources most suitable for each person who uses the tool (CMS, 2022).  

The CMS created the tool to discover its impact on health outcomes, cost utilization, and quality of care. Alex Billioux and Katherine Verlander of CMS CMMI, speak on the entirety of the tool and its implementation strategies. Billioux states the model was created because “the largest drivers of healthcare and healthcare cost fall outside of the clinical care environment.” With this knowledge, increasing the assessment of unmet social needs in clinical settings will hopefully lead to reduced healthcare costs and improved overall health.  

“We cannot talk about advancing health equity for all people without considering their own individualized needs and strengths,” says Cancer Support Community’s Director of Health Equity, Audrey Davis. “The AHC HRSN tool allows us to not only understand how to best link each person to the resources and referrals that they most need at a certain point in time, but also tells us how well-connected and -supported an individual might be in certain domains so that these assets may be leveraged in concert with addressing their needs so that their highest level of health may be attained.” 

Increasing Access and Digital Scaling 

Patient Planning Services now includes the HRSN screening tool on the MyCareReport platform. People with access to the platform can administer the tool in their clinical setting. In addition to digitizing the HRSN tool, the MyCareReport platform has added automated provider referrals and customized personal resource reports for patients who endorse areas of need. This allows for full care coordination and resource allocation with minimal staff bandwidth.    

The platform also provides for easy raw and aggregate data collection to monitor trends, identify gaps, and allocate resources. The addition of HRSN into the screening protocol ensures the social needs of a patient are being considered in a comprehensive screening and referral system. The HRSN screening tool assists in standards for the Enhancing Oncology Model (EOM), which aims to improve personalized care coordination and resource referrals (Centers for Medicare and Medicaid Services, 2022).  

Clinical solutions need to be dynamic and catered around the multiple variables in a person’s life. Exploring new screening measures like the HRSN screening tool helps ensure that the healthcare system is continuing to evolve and advance.  


Billioux, A., K. Verlander, S. Anthony, and D. Alley. 2017. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. 

Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation. The AHC Health-Related Social Needs Screening Tool. Aug. 2022,

“Enhancing Oncology Model: CMS Innovation Center.” Centers for Medicare and Medicaid Services Innovation Center,,and%20manage%20their%20cancer%20care.   

McCarthy, Douglas, et al. “Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update.” The Common Wealth Fund, 2022,

[SIREN: Social Interventions Research & Evaluation Network]. (2017, September 26). Accountable Health Communities: CMS Health-Related Social Needs (HRSN) Screening Tool [Video]. Youtube. 

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