Screening for health-related social needs uses defined questions to identify circumstances that may affect a person's ability to maintain health or obtain care. Examples include difficulty accessing food, stable housing, utilities or transportation.
CMS distinguishes these individual needs from broader social drivers of health, such as community conditions and access to economic opportunities. The terms are related, but recording one person's unmet need does not measure every condition affecting the surrounding community.
Prepare a response before collecting answers
Decide who will review responses, how time-sensitive concerns will be handled and who can help connect patients with resources. Staff should know what they can offer and what requires another team member.
A screening program also needs a process for updating resource information. An accurate answer from a patient is of limited practical use if the only referral offered leads to a disconnected phone number.
Consider a fictional clinic that begins asking about transportation. Before launch, it identifies a staff contact to discuss ride options and a route for informing the clinical team when an appointment remains inaccessible. The screening question and the response process are separate parts of the work.
Use a defined instrument
The CMS Accountable Health Communities screening tool includes five core domains: living situation, food, transportation, utilities and safety. Its companion guide explains administration and scoring, including how skipped questions can affect interpretation.
Use the selected tool's instructions and the organization's approved workflow. Preserve the version and response categories in documentation. If wording or scoring is changed, do not describe the result as an unchanged implementation of the original instrument.
A positive screen should lead to clarification and an appropriate response. It does not establish eligibility for a benefit, confirm that a service is available or show that the need has been resolved.
Explain purpose and privacy
The CMS guide recommends explaining the purpose of screening and preparing staff to address privacy and safety concerns. It also calls for procedures to respond to immediate danger and applicable reporting requirements.
Use an explanation that accurately reflects the local process. Avoid promising absolute confidentiality or automatic assistance. Arrange communication support and an appropriate setting for sensitive questions.
Keep a declined or unanswered question distinct from a negative response. Do not fill in answers based on appearance, insurance type or assumptions about the person's household.
Follow the need through the workflow
Discuss which concerns the person wants help addressing. Record the agreed next action, responsible contact and unresolved barriers. Use the clinical escalation process when a concern requires prompt assessment.
For program review, distinguish how many people were offered screening, how many answered, how many identified a need and how many received useful assistance. These are different questions. A high screening completion rate alone does not demonstrate that community services became more accessible.
Record screening and service delivery separately. community resource referrals can track whether an agency accepted the request. When measuring care coordination, a completed questionnaire belongs in the screening count, not in a count of people who received assistance.
Sources
- Social Drivers of Health and Health-Related Social Needs (accessed 2026-09-17) — CMS.
- A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool (accessed 2026-09-17) — CMS, updated December 2023.