Addressing Social Needs (ASN) Merit-based Incentive Payment System (in the Outpatient Setting) Part 1 of 4 – Food Domain

Percentages of outpatient patients of all ages reflecting whether patients were assessed in four domains of social need: food, housing, transportation, and utilities, and whether the patient received a qualifying follow-up action within the visit for any positive social needs. Qualifying follow-up actions were identified from Gravity Project: adjustment, assistance/assisting, coordination, counseling, education, evaluation of eligibility, provision, and referral.

The ASN eCQM consist of four domains. To report the ASN eCQM measure, all four domains are required. This part 1 is to report the Food Domain. Refer to Transportation, Utility, Housing Insecurity domains for remaining logic,

Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.

This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. All rights reserved.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc.

CPT(R) contained in the Measure specifications is copyright 2004-2023 American Medical Association.

ICD-10 is copyright 2023 World Health Organization. All Rights Reserved.

These performance specifications are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

None

None

None

The 2019 National Academies of Science, Engineering and Medicine (NASEM) Report Integrating Social Care into the Delivery of Health Care identified better awareness of the unmet social needs of defined patients and populations as an important strategy for improving health and social outcomes. (NASEM, 2019). Assessments for social needs also provides an opportunity to improve population health and advance health equity. The measure is aligned with CMS National Quality Strategy goal to address the disparities that underlie our health system, both within and across settings, to ensure equitable access and care for all (Centers for Medicare & Medicaid Services, n.d.). This measure, which focuses on assessment for social drivers of health, is aligned with main objectives of the CMS Universal Foundation (Jacobs et al., 2023). Historical and contemporary discrimination contribute to higher levels of unmet social needs among certain social groups. Systematic assessment and follow-up for unmet social needs may help mitigate of some race-based inequities that exist in material hardships (Odoms-Young & Bruce, 2018). There exist opportunities to improve the rates of assessment for social needs. While some hospitals and outpatient facilities currently screen patients for unmet social needs, few comprehensively and universally screen for multiple unmet needs using standardized and validated tools; collect and transfer data electronically using national interoperability standards; set person-centered goals around unmet needs; and provide goal-oriented actions, such as interventions, referrals, and direct supports (Fraze et al., 2019) Measurement using standardized and validated screening instruments that are collected and transmitted using certified electronic health records (EHRs), aims to make care coordination more effective, enable more efficient measurement, reduce administrative burden, and enhance health ecosystem efficiency.

Identifying and addressing social needs is both a national and international priority toward the goal of health equity. This is evidenced internationally by the guidance of the World Health Organization. Nationally, addressing social needs is woven into the US Department of Health and Human Services Healthy People 2030 Social Determinants of Health objectives. Lastly, commitment to addressing social needs is found in the core policies of US professional organizations such as the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics.  (World Health Organization), (HHS), (AAP).

Output is informational.

Reference Type: Citation

Reference Text: 'American Academy of Family Physicians. (2019, December 12). Advancing Health Equity by addressing the Social Determinants of health in Family Medicine (position paper). AAFP. https://www.aafp.org/about/policies/all/social-determinants-health-family-medicine-position-paper.html'

Reference Type: Citation

Reference Text: 'Fraze TK, Brewster AL, Lewis VA, Beidler LB, Murray GF, Colla CH. Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals. JAMA Netw Open. 2019;2(9):e1911514. Published 2019 Sep 4. doi:10.1001/jamanetworkopen.2019.11514'

Reference Type: Citation

Reference Text: 'Jacobs, D. B., Schreiber, M., Seshamani, M., Tsai, D., Fowler, E., & Fleisher, L. A. (2023). Aligning quality measures across CMS - the universal foundation. The New England Journal of Medicine. https://doi.org/10.1056/NEJMp2215539'

Reference Type: Citation

Reference Text: 'National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/25467'

Reference Type: Citation

Reference Text: 'Odoms-Young A, Bruce MA. Examining the Impact of Structural Racism on Food Insecurity: Implications for Addressing Racial/Ethnic Disparities. Fam Community Health. 2018 Apr/Jun;41 Suppl 2 Suppl, Food Insecurity and Obesity(Suppl 2 FOOD INSECURITY AND OBESITY):S3-S6. doi: 10.1097/FCH.0000000000000183. PMID: 29461310; PMCID: PMC5823283'

Reference Type: Citation

Reference Text: 'US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Social Determinants of Health. https://health.gov/healthypeople/priority-areas/social-determinants-health'

Reference Type: Citation

Reference Text: 'What is the CMS National Quality Strategy? (n.d.). Cms.gov, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy'

Reference Type: Citation

Reference Text: 'World Health Organization. (n.d.). Social Determinants of Health. https://www.who.int/teams/social-determinants-of-health'

Measure consists of four social determinants of health domains: food insecurity, transportation insecurity, utility insecurity, housing insecurity (comprised of housing instability and homelessness). Five informational rates will be reported from each domain in addition to a single overall domain score. 

Overall domain scores are per domain; there is no single aggregated score across multiple domains. 

The overall domain score supports the measure’s mission to increase the percentage of patients who are either negative for social risks or if assessed positive have appropriate intervention. It represents those who are fully screened negative in addition to those who are screened positive AND have documented follow-up plan. 
Overall domain score = Numerator 4 +Numerator 5 / Denominator

Numerator captures whether a social need was documented during the encounter, either through a positive screening during the encounter, or an ICD-10-CM code indicating a diagnosis. ICD-10-CM diagnosis throughout this header refers only to those Z-codes identified in the value sets.

Assessment for social needs can be completed using one of multiple screening instruments referenced in the value sets. Approved screening questions and associated results are represented as direct reference codes (LOINC) instead of value sets. This is for ease of implementation, and ease of reevaluation in the future. 

Notably, Housing domain has an approved screening question that is applicable to both housing instability and homelessness, however, the resulting responses vary: Housing status (LOINC Code (71802-3). 
If encounter has a response of, "I have a place to live today, but I am worried about losing it in the future" (LOINC Code (LA31994-9), this is a POSITIVE result for housing instability; but a NEGATIVE result for homelessness. If encounter has a response of, "I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)" (LOINC Code (LA31995-6), this is a NEGATIVE result for housing instability, but a POSITIVE result for homelessness. If either of these responses are documented, a Follow-Up Intervention Ordered or Performed is required. 

Similarly, if an encounter has a screening for homelessness and result is, "I have housing" (LOINC Code (LA30189-7)), or "I have a steady place to live" (LOINC Code (LA31993-1), measured entity is required to ask about housing instability.

This eCQM is a patient-based measure. 
To encourage documentation and coding of Social Determinants of Health (SDOH) concepts, like food insecurity, this measure only allows for ICD-10-CM codes to meet the diagnosis; SNOMED-CT codes are intentionally not included to capture a diagnosis for this measure.

This measure is intended to have 6 reporting rates for each domain (Numerators 1-5 and Overall Domain Score detailed in Numerator section),   across four SDOH domains, equaling 24 rates overall. All domains do not aggregate into one single overall rate. Food domain is detailed as Population Criteria 1-6; Transportation domain is detailed as Population Criteria 7-12; Utility domain is detailed as Population Criteria 13-18; Housing domain is detailed as Population Criteria 19-24. For ease of reference, each Population Criteria in the human readable includes an in-line description of the domain, numerator #, and written description of the numerator output. 

Initial Population criteria is the same for each domain. Each encounter in the denominator will be attributed to only one of the Numerators 1, 2, 3, 4, or 5 for each domain. Housing domain logic is detailed separately as it accounts for screening and follow-up for both housing instability and homelessness. 

Logic for food, transportation, and utility domains: Identify initial population of inpatient encounters, removing those meeting exclusion criteria. Identify encounters that meet Numerator 1, Numerator 2, Numerator 3, Numerator 4, or Numerator 5.

Numerator 1 are encounters with no documentation of screen, OR a screen but no resulting finding from screen, and no ICD-10-CM diagnosis or decline to answer. 

Numerator 2 are encounters with documentation of patient declined to answer screening question(s). 

Numerator 3 are encounters with a positive finding from screening questions or ICD-10-CM diagnosis, AND no documented Insecurity Follow-Up Intervention Ordered or Performed. 

Numerator 4 are encounters with a positive finding from screening questions or ICD-10-CM diagnosis, AND a documented Insecurity Follow-Up Intervention Ordered or Performed.
Numerator 5 are encounters with a negative finding from screening questions and no ICD-10CM diagnosis. 

Then identify those in the Overall Domain Score (Domain Insecurity Screened Negative or Screened Positive With Intervention; Sum of Numerators 4 and 5): Identify initial inpatient population encounters, removing those meeting exclusion criteria. Identify encounters that meet Numerator 4, sum with those encounters that meet Numerator 5.

Logic for housing domain requires measured entity to have an assessment of both housing instability and homelessness to be considered for Numerator 5.
Identify initial population of inpatient encounters, removing those meeting exclusion criteria. Identify encounters that meet Numerator 1, Numerator 2, Numerator 3, Numerator 4, or Numerator 5. 

Numerator 1 are encounters where patient is not fully assessed for housing instability and homelessness with no documentation of both screens, or screens but no resulting findings from screens, and no ICD-10-CM diagnosis or decline to answer. 

Numerator 2 are encounters with documentation of patient declined to answer screening question(s), or if encounter has one declination and one negative screen. 

Numerator 3 are encounters with a positive finding from either housing instability or homelessness screening questions or ICD-10-CM diagnosis for either, regardless of one being declined, AND no documented Follow-Up Intervention Ordered or Performed.  

Numerator 4 are encounters with a positive finding from either housing instability or homelessness screening questions or ICD-10-CM diagnosis for either, regardless of one being declined, AND a documented Insecurity Follow-Up Intervention Ordered or Performed.

Numerator 5 are encounters with a negative finding from BOTH housing instability and homelessness screening questions and no ICD-10CM diagnosis for either. 

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Patients of all ages who are seen for a qualifying outpatient visit during a one-year measurement period. 

Equals Initial Population

None

Numerator 1: Patients (or proxies, e.g. caregivers, parents, guardians, and so forth) who were not screened for food insecurity and there was no documented ICD-10-CM diagnosis for food insecurity during the measurement period.
Numerator 2: Patients (or proxies, e.g. caregivers, parents, guardians, and so forth) who declined food insecurity screening during the measurement period.
Numerator 3: Patients (or proxies, e.g. caregivers, parents, guardians, and so forth) screened positive for food insecurity or with a documented ICD-10-CM diagnosis of food insecurity during the measurement period, with no followup or intervention performed.
Numerator 4: Patients (or proxies, e.g. caregivers, parents, guardians, and so forth) who screened positive for food insecurity or have an ICD-10-CM diagnosis for food insecurity, with proper intervention or follow-up during the measurement period.
Numerator 5: Patients (or proxies, e.g. caregivers, parents, guardians, and so forth) who screened negative for food insecurity during the measurement period, with no ICD-10-CM diagnosis for food insecurity.
Numerator 6: Food Insecurity Overall Domain Score: Food Insecurity Screen Negative or Screen Positive With Intervention (Sum of Numerators 4 and 5) 

None

None

For every patient evaluated by this measure also identify birth date, payer, race, ethnicity, and sex