Social Risk Factor Screening in Healthcare Quality

Social Determinants and Health Outcomes

Social determinants of health (SDOH), also called social risk factors, are the conditions in which people are born, grow, live, work, and age. These factors, including housing stability, food security, transportation access, employment, education, and social support, significantly influence health outcomes. Research suggests that social and behavioral factors account for a larger share of health outcomes than clinical care alone. CPHQ candidates should understand SDOH screening because quality programs increasingly recognize that clinical interventions alone cannot address the full range of factors affecting patient health.

Screening Tools and Approaches

Several validated screening tools are available for identifying social risk factors:

• PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences): A comprehensive tool aligned with national standards.
• AHC-HRSN (Accountable Health Communities Health-Related Social Needs): Developed by CMS, focusing on housing instability, food insecurity, transportation difficulties, utility needs, and interpersonal safety.
• SDOH screening within EHRs: Many electronic health record systems now include standardized SDOH screening modules using ICD-10 Z codes for documentation.

Integration with Quality Programs

Quality programs integrate SDOH screening by establishing screening workflows at intake and periodic assessments, documenting identified needs in the medical record using standardized codes, referring patients to community resources, and tracking whether referrals result in connected services. The closed-loop referral process (screening, referral, confirmation of service receipt) is the current best practice.

Quality Measures Related to SDOH

Emerging quality measures address SDOH screening rates, documentation of identified social needs, referral completion rates, and the impact of social interventions on clinical outcomes. CMS and NCQA have incorporated SDOH screening into several quality programs, signaling the expectation that healthcare organizations systematically assess and address social risk factors.

Implementation Considerations

Effective SDOH screening requires staff training on sensitive inquiry techniques, workflows that connect identified needs to available resources, community resource directories, partnerships with social service organizations, and data systems that track screening, referral, and resolution. Organizations must also address patient privacy concerns and avoid stigmatizing patients during screening.