Summary
The Accountable Health Communities Health-Related Social Needs Screening Tool is a screening tool developed for the CMS Accountable Health Communities Model. It is used to identify health-related social needs that may affect health, care access, and care planning.
The core screening domains include:
- Housing instability and housing quality problems
- Food insecurity
- Transportation needs
- Utility needs
- Interpersonal safety
The tool is a screen, not a diagnosis. Results should be interpreted with the person’s context, preferences, immediate safety, and available local support pathways.
Scoring
The core social-need domains are interpreted as need present or not indicated based on the person’s responses.
A need is indicated when the response identifies a problem in that domain, such as housing instability or housing quality problems, food insecurity, lack of transportation affecting care or daily needs, or threatened/actual utility shutoff.
The interpersonal safety section uses four items asking how often anyone, including family, physically hurts, insults or talks down to, threatens with harm, or screams/curses at the person. Responses are scored:
- Never = 1
- Rarely = 2
- Sometimes = 3
- Fairly often = 4
- Frequently = 5
The interpersonal safety score range is 4 to 20. A score of 11 or higher indicates a positive screen for interpersonal safety risk in the AHC HRSN tool.
Interpretation
A positive domain screen indicates a reported health-related social need in that domain. It should prompt discussion, confirmation of the need, and consideration of appropriate support options.
Multiple positive domains indicate multiple concurrent social needs. The result should be interpreted as a practical summary of reported needs, not as a severity diagnosis.
For interpersonal safety, a score of 11 or higher indicates potential safety risk. Any safety concern should be handled with appropriate clinical judgement, privacy, local safeguarding procedures, and attention to immediate risk.
Suggested actions
For housing needs, consider clarifying whether the issue is current homelessness, risk of losing housing, or housing quality and safety problems.
For food insecurity, consider whether the person has reliable access to enough food and whether urgent food support or longer-term assistance is needed.
For transportation needs, clarify whether transport barriers are affecting medical appointments, medications, work, daily living, or other essential activities.
For utility needs, clarify whether shutoff is threatened or has already occurred, and whether urgent support is required.
For interpersonal safety concerns, consider immediate safety, privacy, consent, safeguarding responsibilities, and local referral pathways. Avoid assuming that a screening score alone captures the full level of risk.
References
Centers for Medicare & Medicaid Services. The Accountable Health Communities Health-Related Social Needs Screening Tool. https://www.cms.gov/priorities/innovation/files/worksheets/ahcm-screeningtool.pdf
Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. NAM Perspectives. 2017. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool - NAM