Leadership Consortium - Sprint for Social Needs - May Sprint - HRSN Screening Methods and Interpretation

Sep 12, 2026

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May 17, 2023, a subset of Leadership Consortium members met for the “Sync for Social Needs (S4SN)” effort to advance interoperability for social risk factor data. The group reviewed how health-related social needs (HSRNs) are screened and how positive screens are interpreted across five HSRNs: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. Discussions covered screening formats, documentation practices, scoring approaches, thresholds, and the role of clinical judgment. Participants also highlighted opportunities for standardized categorization and reporting using Z-codes, ICD-10 codes, and LOINC codes, and emphasized alignment in tools and data collection.

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HRSN Screening Methods

Questions

Discussion

HRSN Screening Interpretation

Questions

Discussion

Sprint Key Points

Participating Organizations

Leadership Consortium Sprint for Social Needs May Sprint On May 17, 2023, the National Quality Forum (NQF) convened a subset of the Leadership Consortium members to participate in the “Sync for Social Needs (S4SN)” effort to promote interoperability for social risk factor data. This group discussed screening methods and interpretation of positive screens for five health-related social needs (HSRNs): food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. The experiences and expertise of this group can inform data collection and interoperability standards for social risk factor data. HRSN Screening Methods Questions 1. Does your organization have a tool that you use to screen for HRSNs? If so, which tool(s) do you use? 2. Is screening conducted using patient self-report or by having a clinician/staff member ask patients questions and document their responses? 3. How often is screening conducted? Discussion Participants shared their current methods for HRSN data collection. Methods employed by participants include electronic health record (EHR) questionnaires, the Veterans Health Administration Assessing Circumstances & Offering Resources for Needs (ACORN) tool, the Accountable Health Communities (AHC) tool, the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) tool, the North Carolina SDOH screening tool, the Safe Environment for Every Kid (SEEK) screening tool, and homegrown tools. Participants reported that screenings are conducted by clinicians, self-reported by patients, or both, either in-person or through digital tools. Several participants noted that these data are collected annually, while others added that screenings occur sporadically, depending on health encounters, significant medical events, or care plans. HRSN Screening Interpretation Questions 4. For each HRSN, what constitutes a positive screen? For example, if the screening tool includes multiple questions about food insecurity, what responses lead you to consider a patient as screening positive for food insecurity? 5. Are HRSN data – including positive screen results – documented in the patient’s clinical record? Discussion Participants reported a variety of ways to determine a positive screen. Some screening tools allow the user to choose different options for categorizing the scored results based on user preference (e.g., AHC) . Tools may sort patients into high, medium, or low-risk categories based on business rules configured at installation (e.g., Epic) automatically. Other tools set a formal threshold for a positive screen based on formal validation (e.g., PRAPARE) . Binary responses may be more common in homegrown tools, defined by user preference. Clinical judgement is used to augment the screening tool to make final determination of the patient’s level of need for referral to services and is captured in various ways. Several organizations noted they have convened internal workgroups to formally define positive screens for their organization. Some participants document positive screens in EHRs, but few have been able to generate qualitative or quantitative data from this documentation. Participants discussed the growing opportunity for standardized categorization and reporting of HRSN data with the use of Z-codes, ICD-10 codes, and LOINC codes. Sprint Key Points • Many organizations use mixed methods to conduct screenings • Screening frequency is highly variable • Screening tools have advanced to develop scores; these tools guide interpretation but determining whether the screen is positive and indicates the need to refer remains the role of the user and are variably implemented. • Organizations augment score interpretation with clinical judgement and reasoning to confirm the presence of a HRSN (often documented in LOINC) and decide whether to refer (often documented in Z codes) • All participants acknowledge the value

FAQs

What was the purpose of the May Sprint convening?

Members gathered for the S4SN effort to promote interoperability for social risk factor data by discussing screening methods and interpretation of positive screens for health-related social needs.

How are HRSNs screened in practice according to participants?

Screening is conducted using clinician questioning, patient self-report, or both, through in-person or digital tools. Examples include EHR questionnaires and multiple established screening tools, along with homegrown methods.

How do organizations determine whether a screen is positive?

Positive screens are determined through different approaches, including tool-based categorization, business-rule scoring, formal validation thresholds, binary responses in some homegrown tools, and clinician judgment. Internal workgroups may also define positive criteria.

Sep 12, 2026

Upload by Sarah