Screening for Social Risk: A Call to Action

Feature Story

Screening for Social Risk: Call to Action

By Rich Sheward, MPP, Children’s Health Watch, Kathryn Jantz, MSW, MPH, HealthBegins

Published October 31 2024

 

Introduction

Social risk screening goes by many names – social needs screening, health-related social needs (HRSN) screening, social drivers of health (SDOH) screening, to name a few. These terms refer to the asking of standardized questions to assess whether someone may need food, housing, or other social support. Many Medicaid Agencies have incorporated social risk screening and referral into Medicaid Managed Care Organizations (MCOs) contracts, hospital reimbursement methodologies, and provider value-based care (VBC) strategies. However, screening requirements vary widely in terms of social risk domains, population, tools, frequency, follow-up requirements, accountability, and transparency. For example, many Medicaid requirements only implicitly include screening for food security, the most prevalent social need for Medicaid enrollees. Thus, there is an opportunity for food partners to advocate for:

• improvements in screening requirements, 
• improvements in screening implementation,
• dissemination of screening data to inform broader anti-hunger efforts, 
• and enhancements of strategies to address food risks once identified.

This blog offers guidance for food partners, advocates, and Medicaid agencies on the importance of screening to address food needs. We’ll talk about:

1. Why social risk screening is cost effective and useful
2. Discuss a recent USPSTF study about food security screening
3. Best practices for screening implementation
4. How we can collectively expand and improve social risk screening through Medicaid policies and procurement processes. 

Social Risk Screening: A Cost-Effective First Step

Several key factors make social risk screening an effective, achievable and important foundation for Medicaid agencies to improve the health of enrollees and their families. These include: 

 

1. Low Cost: Implementing social risk screening doesn’t require significant upfront costs for Medicaid agencies who often incorporate screening into Medicaid Managed Care capitation rates. Simple questionnaires in electronic health records or case management systems, and in some cases, workflow modifications for healthcare staff, can enable Medicaid enrollees to share this information and receive support.
2. High Return: Research has shown that what happens outside the doctor’s office – including whether someone can access and afford nutritious food – can impact health more than clinical care itself. In fact, food insecurity adds an estimated $160 billion to annual healthcare costs in the US.
3. Normalize and Destigmatize Social Needs: Some people avoid using food-related social resources due to stigma. A clinical provider can cultivate respect and trust with their patient so that they are more likely to share their social needs and accept help. By asking these critical questions in a clinical setting, providers can reframe social risks and accessing resources as essential to improving health. Raising awareness through non-judgmental screening normalizes these conversations for both staff and patients.
4. Common Starting Place: Social risk screening provides a foundation for understanding patients’ overall well-being. The Social Interventions Research and Evaluation Network  Social Care Logic Model proposes that social risk screening is an opportunity to connect patients with social and medical care, and improve clinical care plans. Many healthcare organizations recognize this value and support food insecurity screening as part of standard care. Food insecurity screening can be an on-ramp to Food is Medicine services like produce prescriptions, medically tailored groceries, medically tailored meals, and/or navigation assistance with accessing the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). 
5. Increase Enrollment in Government Benefits: Millions of Medicaid enrollees are likely eligible for but not enrolled in both SNAP and WIC, which are federally funded programs that improve food security and health outcomes. Social needs screening can be the first step in connecting Medicaid enrollees to these vital benefits.
6. Alignment with Quality Metrics and Programs: Screening is being incorporated into quality monitoring and payment programs such as through the inclusion of the Social Needs Screening HEDIS (Healthcare Effectiveness Data and Information Set) measure. Screening has been included as a requirement in Joint Commission Health Equity accreditation (which accredits over 22,000 healthcare organizations) and in the CMS Hospital Inpatient Quality Reporting Program. Cancer hospitals, psychiatric facilities, and kidney dialysis centers are also being required to screen patients for food insecurity. Medicaid agencies incorporating social risk screening requirements would be aligned with these other efforts. 
7. Community-Level Insights: By aggregating data from social risk screenings, states can gain valuable insights about specific challenges within their communities such as gaps in community resources and provider training needs. This information can guide targeted interventions and resource allocation, improving health equity.

What’s the Latest Evidence Around Food Insecurity Screening?

The US Preventive Services Task Force (USPSTF), a panel of experts who make recommendations about preventive healthcare, recently reviewed the evidence on food insecurity screening. While they couldn’t definitively say whether screening improves overall health outcomes, they did find some encouraging insights. Brief screening tools, like the two-question “Hunger Vital Sign,” are effective at identifying people at risk for food insecurity. 

 

The review had some significant limitations that are worth noting. The review looked at studies where patients were referred to various food resources, including WIC or SNAP. However, the review’s authors acknowledge that they didn’t actually factor in evidence on the effectiveness of WIC and SNAP, despite both programs being linked to improved health outcomes in previous studies. Increasingly, healthcare teams and organizations are connecting patients to SNAP and WIC through referrals, and sometimes, direct application assistance from community health workers and other support staff. The study’s scope was also restricted to interventions published in peer-reviewed literature (ignoring a large body of evidence from the field), and focused only on primary care settings, leaving out many successful community-based initiatives.

 

Research from Children’s HealthWatch, which has interviewed over 75,000 caregivers of young children since 1998, paints a clear picture of why food security screening is crucial. When families don’t have enough food, it affects every aspect of their well-being. Children may experience poor health and development, or face behavioral challenges. Studies on adults also show how food insecurity is associated with poor health outcomes like going to the emergency department more and heart disease risk. 

 

While the official recommendation might be unclear, what is clear is the connection between food and health. Healthcare providers are right to be concerned about their patients’ access to food. We should not interpret the USPSTF report as evidence that we should stop food insecurity screening in healthcare; instead, we should continue these important  conversations to best understand patients’ life situations and continue improving our solutions for connecting people to SNAP, WIC, and community food resources. 

Strong Social Risks Screening Policy for Children and Families

Strong Medicaid policies can hold Medicaid payers and providers accountable for completing social risk screening, and provide them with the needed financial or technical support. Most often, social risk screening requirements appear in MCO contracts or in contracts with providers for value-based payment models. The MFSN team reviewed publicly available state MCO contracts and other key documents and identified several features that could enhance the impact of social risk screening for children and families: 

 

• Screening population: Everyone  

Sometimes, outreach and social risk screening is only required for people with specific illnesses or high use of hospital and emergency department services. However, with universal screening of Medicaid enrollees, we could reach many more food and nutrition-insecure families who don’t meet these criteria, which would ensure that social risks are identified and addressed early. Increasingly, many states require social needs screening for all Medicaid enrollees (as you can see on the Medicaid Food Security Network Policy Dashboard. Note: most states refer to it as “social needs screening” rather than “social risk screening”). 

• Screening Frequency: Annual 

Annual or more often as warranted, screening can address the changing needs of families. Many states are incorporating screening into the federally mandated health risk assessment that must occur within ninety days of Medicaid enrollment. 

• Screening Tool: Recognized Standardized Screening Tool 

Using a standardized screening tool can be important to ensure  1) the screening tool accurately identifies social risks 2) data can be aggregated and interpreted correctly and 3) screening is conducted in a way that reduces stigma and supports improved connection to resources. In Iowa, Hawaii, Nebraska, and New Hampshire, the MCO contract requires that MCOs either use state-defined screening questions or submit screening tools to the state for approval. 

• Screening follow-up: Clear expectations to provide support to households that  screen positive

The Gravity Project has identified eight possible interventions that could follow a positive screening for food insecurity risk: assessment, assistance, coordination, counseling, education, evaluation of eligibility, provision and referral.This definition of intervention following screening has been adopted by the NCQA for their new Social Needs HEDIS measure. For children and families, one of the most important follow-ups is assistance in applying for SNAP and WIC. For example, Oklahoma’s MCO contract requires that MCOs provide enrollees with referrals to social services based on assessed risk, track and report on the outcomes of those referrals, partner with CBOs, and employ or collaborate with community health workers or other traditional health workers to address enrollees’ social needs. 

• Accountability and Transparency: 

Regularly reporting on screening results can ensure that screening is implemented as intended. For example, New Hampshire publishes the percent of Medicaid enrollees who successfully received a health risk assessment on a quarterly basis. Other states are developing processes to capture and share member-level details on social risk screening results and follow-up. In Arizona, Medicaid MCOs are required to use the state’s approved closed-loop referral system to screen and refer members annually for social risks and needs. 

• Screening Financial Incentives: 

Linking screening to financial incentives or reimbursement can increase screening rates and support the time it takes for a provider or MCO to do screening. For example, the Iowa MCO contract requires that MCOs reimburse providers for SDoH Codes or Z codes, which are standardized electronic health record codes that enable documentation of social risks. 

How HRSN Policies are Made

While working with individual clinics, health systems, or MCOs to implement social risk screening is important, we also have opportunities to advocate for changes to Medicaid MCO contracts that can lead to sweeping statewide changes. These contracts may include requirements for screening to be carried out by either MCOs or their provider network. Medicaid MCO contracts are revised on a regular basis, often annually. These revisions tend to include changes that are mutually agreeable to the MCOs and to the state. Small changes to screening requirements in a contract may be possible in these regular updates. 

 

Larger contract changes are done during the  “procurement process”. A procurement process is when a state releases a request for proposal (RFP) for organizations to apply to be Medicaid MCOs – you can think of this like a job listing for MCOs. In that procurement process, the state releases updated scopes of work for those MCOs. How often states make MCOs reapply for their job or go through this procurement process is different state by state but is usually around five to ten years. The procurement process itself can be up to a two-year process. For example, that might break down to a year of the state working internally, three months for MCOs to respond to a request for proposals, three months to select awardees, and six months for the MCO to be ready to implement. 

 

Because of the long lead time to renewals and the annual updates, food security stakeholders can engage their Medicaid agency at any point about social risk screening but should accelerate and increase their efforts if there is an upcoming procurement process. Your state’s Medicaid agency website and/or representatives can tell you when the next procurement process will take place. We at the Medicaid Food Security Network will also do our best to let you know about re-procurement processes when we hear about them. 

Want to Learn More and Connect with Others Interested in Screening?

One of the most common standardized food security screening tools is the Hunger Vital Sign™, which involves two questions and has strong accuracy. Individuals interested in using this tool can attend the Hunger Vital Sign National Community of Practice (HVS NCoP) co-convened by Children’s HealthWatch and the Food Research & Action Center (FRAC). The HVS NCoP facilitates conversations and collective action among a wide range of stakeholders interested in addressing food insecurity through a healthcare lens. The overarching goal and purpose of the HVS NCoP is to rapidly share leading best practices and data on food insecurity screening/intervention activities and strategies to scale what works. They hold quarterly virtual meetings to facilitate a collaborative forum and a venue where multiple stakeholders gather to disseminate research and best practices, incubate innovative ideas, and inform and influence large-scale policy and practice change resulting in evidence-based innovations to alleviate food insecurity and improve population health outcomes. Join the Community of Practice through this form.