A New Screening Tool Identifies Unmet Health-Related Social Needs (HRSN)

November 7, 2023
A seated group of talking men and women

Stock photo posed by models, sourced by Getty Images.

The Center for Medicare and Medicaid Innovation developed the HRSN Screening Tool, which may lead to reduced healthcare costs and improved overall health.

In a comprehensive healthcare system, assessments and interventions must consider all factors that contribute to a person’s health. This means conducting well-rounded assessments that consider health-related social needs like housing instability, food insecurity, transportation, and other factors that can lead to poor health outcomes for people. 

Social factors impact a wide range of health outcomes. Researching how to address them is the first step in creating solutions.  

Health-related social needs and social determinants of health are two components to consider when delving into an individual’s social context. While social determinants of health and health-related social needs are both crucial to consider in healthcare services, they differ slightly: 

Social determinants of health are factors associated with the environments in which people live. These factors are heavily centered around the built environment, economic stability, and community.  

Health-related social needs impact how and to what degree a person can maintain their health (CMS, 2022). They are the unmet needs that may happen because of certain social determinants of health. While our understanding of social determinants of health has greatly expanded in recent years, health-related social needs remain less addressed. 

Social determinants of health and health-related social needs have profound impacts on a person’s health and how they are able to receive care (Billioux et al, 2017). Identifying unmet health-related social needs presents an opportunity to build dynamic solutions that align with people’s daily life. 

A muti-study review found that addressing social needs such as nutrition, housing instability, transportation, and other factors has made a positive impact in driving healthcare utilization and overall health outcomes (McCarthy et al, 2022). Another result was cost reduction. The importance of acknowledging health-related social needs is evident, yet there are few tools to address these unmet needs. 

To better assess unmet health-related social needs in clinical settings, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) developed the Accountable Health Communities Health-Related Social Needs (AHC HRSN) Screening Tool.

This 10-item tool is designed to improve health outcomes via treatment and resource referrals for patients, aligning with the principles of the Accountable Health Communities Model. Assessing the main domains of housing instability, food insecurity, transportation problems, utility help needs, and interpersonal needs provides insight on the community services and resources most suitable for each person who uses the tool (CMS, 2022).  

CMS CMMI created the tool to discover its impact on health outcomes, cost and utilization, and quality of care. Alex Billioux and Katherine Verlander, of CMS CMMI, discussed the tool and its implementation strategies for use in the Accountable Health Communities model program. Billioux explained that the model was created because “the largest drivers of healthcare and healthcare cost fall outside of the clinical care environment.” The hope is that implementation of social needs assessments in clinical settings may lead to reduced healthcare costs and improved overall health.  

We cannot talk about advancing health equity for all people without considering their own individualized needs and strengths. The AHC HRSN tool allows us to not only understand how to best link each person to the resources and referrals that they most need at a certain point in time, but also tells us how well-connected and supported an individual might be in certain domains so that these assets may be leveraged in concert with addressing their needs so that their highest level of health may be attained.

Audrey Davis
Director of Health Equity, Cancer Support Community

MyCareReport Platform Includes the HRSN Screening Tool

Our digital mental health assessment and referral platform, MyCareReport, now includes the HRSN Screening Tool to administer in clinical settings. The addition of HRSN ensures that patients’ social needs are being considered in a comprehensive screening and referral system. Our platform provides automated provider referrals and customized personal resource reports for patients’ areas of concern. This allows for full care coordination and resource allocation with minimal staff bandwidth. 

Learn More About MyCareReport Platform


Including the HRSN Screening Tool in clinical screening protocol fulfills Enhancing Oncology Model (EOM) standards. The EOM aims to improve personalized care coordination and resource referrals (Centers for Medicare and Medicaid Services, 2022). New screening measures like the HRSN Screening Tool help ensure that the healthcare system is continuing to evolve and advance.