Opinion

Inadequacy of Current Screening Measures

VIEWPOINT
for Health-Related Social Needs

Arvin Garg, MD, MPH In 2022, the Centers for Medicare & Medicaid Services fessionals must respect each patient’s decision to seek,
Child Health Equity (CMS), along with standard-setting organizations such or not seek, assistance for social needs.
Center, Department of as the National Committee for Quality Assurance (NCQA)
Pediatrics, UMass
Memorial Children’s
and The Joint Commission, established new quality mea- Lessons From the Pediatric Experience
Medical Center, UMass sures aimed at promoting health equity.1-3 Many of these With HRSN Screening
Chan Medical School, measures center around screening patients for health- Pediatrics has led the medical field in devising up-
Worcester, related social needs (HRSN). For example, starting in stream, innovative approaches to understanding and ad-
Massachusetts; and
UMass Memorial
2024 CMS will require HRSN screening during adult hos- dressing families’ social needs. In 2016, the American
Health, Worcester, pitalizations. There is an indisputable connection be- Academy of Pediatrics was the first medical organiza-
Massachusetts. tween social factors (eg, low food security, housing in- tion to recommend HRSN screening at visits. This rec-
stability), structural racism, poverty, and health. ommendation accelerated its adoption into pediatric pri-
Alison LeBlanc, MS, However, without additional considerations, these well- mary care. Implementation studies, however, have found
PMP
Child Health Equity intentioned mandates will impede progress in health eq- inequities with the distribution of HRSN screeners and
Center, Department of uity and have the potential to increase long-standing ra- receipt of referrals to social service agencies based on
Pediatrics, UMass cial and socioeconomic inequities. parents’ language and race and ethnicity.6,7 Despite pa-
Memorial Children’s
rental support for HRSN screening and an opportunity
Medical Center, UMass
Chan Medical School, The Paradoxical Potential Harm for parents to connect and receive support from their pe-
Worcester, of HRSN Screening diatrician, there is also great concern particularly from
Massachusetts; and Policymakers often use the terms social risk and social low-income minoritized parents. Their concerns in-
UMass Memorial
Health, Worcester,
needs interchangeably with HRSN. Yet, social risks and clude feelings of shame, being judged and discrimi-
Massachusetts. social needs are different. Social risks are individual- nated against by the health care team, fear that disclos-
level adverse social factors while social needs are based ing needs will lead to filings with child protective services
Jean L. Raphael, MD, on an individual’s priorities and perceptions of needs.4 and removal of their children, and frustration with dis-
MPH closing sensitive needs without getting
Section of Academic
General Pediatrics, acknowledgment and help.8
Baylor College of Nonetheless, almost three-quar-
Medicine, Houston, [T]hese well-intentioned mandates ters of low-income parents received
Texas; and Center for
referrals for unmet social needs after
Child Health Policy and will impede progress in health equity
Advocacy, Baylor reporting a desire for help on the WE
College of Medicine, and have the potential to increase CARE (Well-child care visit, Evaluation,
Houston, Texas.
long-standing racial and Community resources, Advocacy, Refer-
ral, Education) social needs screener. This
socioeconomic inequities. simple screening and referral interven-
tion improved resource receipt for
Screening for social risk vs social needs requires differ- families.9 Applying an equity lens to social needs screen-
ent methods; there is little overlap between social risk ing, along with determining how HRSN screening is in-
screening, which relies on validated screening measure- troduced to patients, matters critically and empathy,
ment tools, and social need screening, which queries epistemic trust, respecting parents’ autonomy and dig-
whether a patient desires assistance.5 Just like any nity, and leveraging existing relationships are core fac-
screening tool, social risk screening instruments have in- tors necessary for patients to share their social needs will-
herent fallibilities including false-positives and false- ingly and openly. Unfortunately, health systems have
negatives, yet many health systems have designed and paid little attention to these critical factors in implement-
implemented their own screening instruments without ing HRSN screening. This lapse may have dire unin-
Corresponding
examining these key issues. Social risk screening may in- tended consequences.
Author: Arvin Garg,
MD, MPH, Child Health advertently emphasize paternalistic care whereby clini-
Equity Center, cians attempt to address patient risks with motiva- A Path Forward for HRSN Screening
Department of tional interviewing techniques to promote behavioral We suggest the following strategies for improving HRSN
Pediatrics, UMass
Memorial Children’s
changes. Our assumption should always be that pa- screening for standard-setting regulatory bodies and
Medical Center, UMass tients (unless incapacitated) know best what their un- health systems.
Chan Medical School, met needs are, eg, if they have enough food for them-
55 Lake Ave N,
selves. Given the mistrust and irreparable generational Standard-Setting Regulatory Bodies
Worcester, MA 01655
(Arvin.Garg@ trauma health systems have created among racialized mi- Incentivize health systems to assist patients with their
umassmemorial.org). noritized and/or low-income patients, health care pro- HRSN. We recommend the emphasis should be changed

jama.com (Reprinted) JAMA September 12, 2023 Volume 330, Number 10 915

© 2023 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 09/13/2023

 Opinion Viewpoint

to incentivize health systems to partner with patients—leveraging
a shared decision-making approach—to address their social needs.
This will require authentic bidirectional conversations, cultural hu-
mility, and creation of novel partnerships and sharing of data be-
tween health care and social service organizations. It would also re-
quire novel measures incorporating patients’ experiences with having
their health care team assisting them with addressing their needs.
We are encouraged that addressing social needs is a requirement for
The Joint Commission’s standard and appears that CMS will ulti-
mately also incentivize addressing patients’ unmet needs beyond
screening.
Move away from social risk and toward social need screening.
As stated earlier, social risk screening as currently constituted in
screeners such as the CMS Accountable Health Communities HRSN
or PRAPARE has the unintentional consequence of eroding pa-
tients’ dignity and autonomy. Shifting HRSN screening to social needs
screening and relying on patients’ desire for assistance for needs that
they experience firsthand to generate referrals is a crucial step in pro-
viding patient-centered, empathetic, and equitable social care.
Health Systems
Ensure staff administering HRSN screening have ongoing antiracist
and cultural humility training. Given that Black and Latine Americans
disproportionately live in poverty and face racism in the health sys-
tem, and in every aspect of their daily lives, prior to implementing
HRSN screening, it will be necessary to conduct unconscious bias,
cultural humility, and empathy building training with all staff and
health professionals involved with screening and addressing pa-
tients’ social needs. Ongoing booster sessions, reviewing case ex-
amples, and providing feedback will be critical to mitigate harm and
ensure the sustained equitable delivery of social care.
Codesign social care support programs with patients, staff, and
community members. We suggest that health systems recruit, and
appropriately compensate, patients, staff, and community mem-
bers to serve as consultants supporting the codesign of hospital-
based social care support programs that partner with existing com-
munity-based social service agencies. These individuals, compared
with health system leaders, have a unique perspective on the his-
toric tensions between the health care system and the communi-
ties they serve and are well-positioned to design innovative pro-
grams to address the food, transportation, educational, and job
training needs of patients and their community.
Advocate for a robust social safety net. The remedies for HRSN
lie outside the walls of health systems. Evidence demonstrates that
a strong social safety net including public benefit programs, such as
Supplemental Nutrition Assistance Program (SNAP) and Women, In-
fants, & Children Nutrition Program (WIC), improve health.10 If health
systems want to effectively address their patients’ unmet needs, they
must advocate locally and nationally for evidence-based social policy
changes. Unfortunately, health systems have often missed oppor-
tunities to use their vaulted status to engage and support their sur-
rounding community as well as protest inequitable racist policies such
as redlining or segregation. Just as health systems aim to provide
evidence-based medical care, they should also advocate for evi-
dence-based social policies that promote health—and health
equity.
Conclusions
A focus on health equity by CMS and standard-setting organiza-
tions is long overdue. Unfortunately, as currently constituted by regu-
latory organizations, HRSN screening will not fulfill its intended goal
of advancing health equity. Screening must be implemented with
caution, humility, and empathy, and with an equity lens to under-
stand the needs of marginalized patients and communities. Health
systems should support patients, staff, and community members in
the design of social care programs that have the potential to pro-
mote health equity while also advocating for health-promoting safety
net programs. Now is the time for policymakers and health sys-
tems to meaningfully invest in holistically addressing health-
related social needs for their patients and communities.

ARTICLE INFORMATION
Published Online: August 21, 2023.
doi:10.1001/jama.2023.13948
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Jacobs DB, Schreiber M, Seshamani M, Tsai D,
Fowler E, Fleisher LA. Aligning quality measures
across CMS: the universal foundation. N Engl J Med.
2023;388(9):776-779. doi:10.1056/NEJMp2215539
2. Reynolds A. Social need: new HEDIS measure
uses electronic data to look at screening,
intervention. Accessed July 3, 2023. https://www.
ncqa.org/blog/social-need-new-hedis-measure-
uses-electronic-data-to-look-at-screening-
intervention/
3. R3 report: requirement, rationale, reference.
Accessed July 3, 2022. https://www.
jointcommission.org/-/media/tjc/documents/
standards/r3-reports/r3_disparities_july2022-6-20-
2022.pdf
4. Alderwick H, Gottlieb LM. Meanings and
misunderstandings: a social determinants of health
lexicon for health care systems. Milbank Q. 2019;
97(2):407-419. doi:10.1111/1468-0009.12390
5. Bottino CJ, Rhodes ET, Kreatsoulas C, Cox JE,
Fleegler EW. Food insecurity screening in pediatric
primary care: can offering referrals help identify
families in need? Acad Pediatr. 2017;17(5):497-503.
doi:10.1016/j.acap.2016.10.006
6. Brochier, A, Messmer E, Tripodis Y, Drainoni ML,
Garg A. Racial and ethnic inequities in families’
receipt of referrals for unmet social needs in
pediatric primary care. Presented at: Pediatric
Academic Societies meeting; 2022: 93.211.
7. Dolce M, Keedy H, Chavez L, et al. Implementing
an EMR-based health-related social needs screen in
a pediatric hospital system. Pediatr Qual Saf. 2022;7
(1):e512. doi:10.1097/pq9.0000000000000512
8. Schleifer D, Diep A, Grisham K. It’s about trust:
parents’ perspectives on pediatricians screening for
social needs. United Hospital Fund. Accessed July 3,
2022. https://uhfnyc.org/publications/publication/
its-about-trust-SDH/
9. Garg A, Toy S, Tripodis Y, Silverstein M,
Freeman E. Addressing social determinants of
health at well child care visits: a cluster RCT.
Pediatrics. 2015;135(2):e296-e304. doi:10.1542/peds.
2014-2888
10. Bradley EH, Canavan M, Rogan E, et al.
Variation in health outcomes: the role of spending
on social services, public health, and health care,
2000-09. Health Aff (Millwood). 2016;35(5):760-
768. doi:10.1377/hlthaff.2015.0814

916 JAMA September 12, 2023 Volume 330, Number 10 (Reprinted) jama.com

© 2023 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 09/13/2023