

PIMSH 18 Resolution or Improvement of a Health-Related Social Need
Measure Description: Percentage of patients 18 years or older who screen positive for 1 or more of the 5-core health-related social needs (HRSNs), including food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety; and have at least 1 of their HRSNs resolved or improved within 6 months.
Relevance to Value Based Care: Health-related social needs encompass a range of non-medical factors that influence an individual's health status, including socioeconomic status, housing stability, food security, access to transportation, social support networks, and exposure to discrimination or violence. By recognizing and addressing these needs, clinicians can help patients overcome barriers to accessing healthcare, improve treatment adherence, and enhance overall well-being.
Numerator: Patients who report resolution of at least 1 health-related social need.
Numerator note:
Resolution is defined as patient indicates they no longer need assistance for 1 or more HRSNs identified during initial screening. The absence of a 5-core HRSN charted during a subsequent screening is indicative of resolution.
If more than one screen occurs during the 6-month follow up, refer to the latest (most current) screening results.
Denominator: All patients 18 years or older with 2 or more visits who screened positive for 1 or more of the 5-core domains included in a standardized HRSN screening.
Definitions:
5 Core Domains – food insecurity, housing instability, transportation needs, utilities difficulties, and interpersonal safety.
Denominator Identification Period – July 1st of the previous performance period through June 30th of the current performance period.
Examples of standardized HRSN Screening Tools include the following, but are not limited to:
NCCN Distress Thermometer (note- all items listed under “Practical Concerns” are considered direct or indirect concerns related to the 5 core domains)
Accountable Health Communities Health-Related Social Needs Screening Tool
The Protocol for Responding to and Assessing Patients’ Risks and Experiences (PRAPARE) Tool
WellRx Questionnaire
American Academy of Family Physicians (AAFP) Screening Tool
Denominator Exclusion: Patients who have died prior to 6-month follow up. Patients who are actively enrolled in hospice during the 6-month follow up.
Denominator Exception: Patient declined assessment. Patient declined assistance.
Telehealth: Yes
Scoring: New measure in its first year: 7-point floor, unless same year benchmark established then 7-10 points.
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