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5 Trends and Policies Impacting Social Determinants and Outcomes

Changes and Opportunities Ahead

Social, economic, and environmental conditions account for 80% of a person’s modifiable contributors to health outcomes. The focus on social determinants of health in 2023 is uniting payers and providers to increase their efforts to find solutions and improve outcomes. Driven by policy and payments, change is coming.

Below are the top five trends impacting change.


Hospitals will be required to report what portion of their population is screened for various social determinants of health (SDOH) and how many screen positive in each category. CMS’s new SDOH quality measures were published in the 2023 Medicare Hospital Inpatient Prospective Payment System rule, released on August 1.

Hospitals will capture screening and identification of patient-level, health-related social needs—such as food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. By screening for and identifying such unmet needs, hospitals will be in a better position to serve patients holistically by addressing and monitoring what are often key contributors to poor physical and mental health outcomes.

For greater insights into the SDOH quality measure, click here.


Medicare Advantage and Managed Medicaid programs create financial incentives for plan sponsors to address members’ health and wellness needs.

The CHRONIC Care Act allowed for a greater range of “health-related” supplemental benefits that could be offered; it also provided flexibility for supplemental benefits that could be targeted to particular groups that would benefit from them. Plans have further flexibility to target benefits to people with specific chronic conditions if the benefits have a reasonable expectation of improving or maintaining health and function. The rollout of these new benefits is ongoing, and a limited number of plans are offering such benefits to date.

For the year 2023, The National Committee for Quality Assurance added a HEDIS measure for social needs screening called the Social Need Screening and Intervention.

In a recent survey looking at social determinants specific to delivery improvement findings indicate:

  • 37% of plans intend to improve screening for socioeconomic barriers known to impact health or health outcomes.
  • 34% of plans intend to improve care coordination for services that address socioeconomic barriers.
  • 31% of plans intend to improve multidisciplinary team models (e.g., social worker, CHW, doulas).
  • 28% of plans intend to improve referrals to community-based organizations to address socioeconomic barriers.

A study published in the Journal of General Internal Medicine found the top 20 payers combined spent at least $1.87 billion on social determinants of health from 2017 through 2021. The top six payers contributed almost three-quarters of that amount.

Social Need Screening and Intervention

To encourage health plans to assess and address the food, housing, and transportation needs of their patient populations, this measure helps health plans identify specific needs and connect members with resources necessary to address unmet social needs. This measure assesses members who were screened, using prespecified instruments, at least once during the measurement period for unmet food, housing, and transportation needs, and who received a corresponding intervention if they screened positive.

  • Food Screening. The percentage of members who were screened for food insecurity.
  • Food Intervention. The percentage of members who received a corresponding intervention within one month of screening positive for food insecurity.
  • Housing Screening. The percentage of members who were screened for housing instability, homelessness, or housing inadequacy.
  • Housing Intervention. The percentage of members who received a corresponding intervention within one month of screening positive for housing instability, homelessness, or housing inadequacy.
  • Transportation Screening. The percentage of members who were screened for transportation insecurity.
  • Transportation Intervention. The percentage of members who received a corresponding intervention within one month of screening positive for transportation insecurity.


CMS released the first-ever Home-and Community-Based Services (HCBS) quality measure set to promote consistent quality measurement within and across state Medicaid HCBS programs. The measure set is intended to provide insight into the quality of HCBS programs and enable states to measure and improve health outcomes for people relying on long-term services and support (LTSS) in Medicaid.

The release of this voluntary measure set is also a critical step to promoting health equity among the millions of older adults and people with disabilities who need LTSS because of disabling conditions and chronic illnesses.

Nationally, over 7 million people receive HCBS under Medicaid, and Medicaid-funded HCBS accounts for $125 billion annually in state and federal spending. Implementation of the HCBS quality measure set will create opportunities for CMS and states to promote more consistent use, within and across states, of nationally standardized quality measures in HCBS programs to promote health equity and reduce disparities in health outcomes among this population.

To review the HCBS quality measure, click here.


CMS released guidance on an innovative opportunity for states to address health-related social needs for people with Medicaid coverage through the use of “in lieu of services and settings” in Medicaid Managed care.

This option will help states offer alternative benefits that take aim at a range of unmet health-related social needs, such as housing instability and food insecurity, to help enrollees maintain their coverage and to improve their health outcomes.

Main Trends in SDOH State Requirements

  • Many states are requiring MCOs or provider networks to screen enrollees for SDOH needs.
  • States are increasingly requiring MCO care management programs to incorporate SDOH to coordinate with community-based organizations and ensure referrals to social services and supports.
  • Recent RFPs have included requirements that MCOs incorporate SDOH into their quality assessment and performance improvement (QAPI) programs and that MCOs provide SDOH training for staff.

See details of the guidance here

5. ACO Advance Investment Payments To Address Social Determinants

Beginning January 1, 2024, CMS is providing a new option in the Shared Savings Program to make advance shared savings payments to certain ACOs. The advance investment payments will provide an opportunity for many entities in rural and underserved areas to join together as ACOs, build the infrastructure needed to succeed in the program, and promote equity by holistically addressing beneficiary needs, including social needs.

Under the final policy, an ACO must use an advance investment payment to improve the quality and efficiency of items and services furnished to beneficiaries by investing in increased staffing, health care infrastructure, and the provision of accountable care for underserved beneficiaries, which may include addressing social determinants of health.

A Message from Lisa Remington


We kick off 2023 by announcing Remington’s Home Care Leadership Think Tank, a virtual educational platform offering live, online strategy and improvement programs to support the advancement and future of home-based care.

The Think Tank’s framework empowers and inspires new levels of strategic thinking about the future of home-based and community-based and is dedicated to advancing home care’s growth, guiding forward-thinking solutions, and improving care delivery through mutually beneficial referral partnerships.

We invite you to learn about our educational programs to increase business intelligence, apply working knowledge to day-to-day decisions, and support future readiness. Click here to learn more.

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