CMS’ SDOH Measures | Deep Dive Into SDOH-1, SDOH-2 and HCHE

The health community has known for a long time that social risk factors can negatively impact a person’s health, including worse outcomes and more time spent in hospitals. We’ve authored several blogs on the subject of Social Determinants of Health (SDOH)- What is SDOH and why it matters , SDoH Studies/Research, SDOH Screening tools, and Government Support for Social Determinants of Health (SDOH) Programs. The purpose of this blog is to talk through the CMS Measure Details: SODH-1, SDOH-2, and Hospital Commitment to Health Equity (HCHE). This blog will objectively lay out the rules and requirements, then offer a perspective on what we are seeing in the market and our thoughts on how to approach these measures.

Introduction and Evolution of CMS SDOH Reporting  

Three SDoH Measures were introduced in the 2023 IPPS Final Rule- the Hospital Commitment to Health Equity (HCHE), Screening for Social Drivers of Health (SDOH-1), and Screen Positive Rate for Social Drivers of Health ( SDOH 2). The HCHE is a mandatory IQR requirement where hospitals attest to whether or not the organization is reviewing and prioritizing equitable care. Screening for Social Drivers of Health (SDOH-1), and Screen Positive Rate for Social Drivers of Health ( SDOH 2), are process measures that were voluntary in 2023, but required in 2024. Fast forward to the latest and greatest 2025 IQR Hospital requirements, and nothing has changed- these 3 measures are required as part of IQR reporting. For the outpatient world, these 3 measures were more recently introduced, and rolled out in similar fashion- OPPS 2025 includes HCHE as a mandatory reporting requirement, and SDOH 1 & 2 as voluntary for 2025, but mandatory for 2026. 

SDOH-1 & 2: Screening Requirements and Reporting

All patients admitted to the hospital are eligible for screening. The screening process can occur anytime during the hospital admission or prior to discharge. There are 5 domains that the screening process needs to cover:

• Food Insecurity- Food insecurity is defined as limited or uncertain access to adequate quality and quantity of food at the household level.
• Housing Instability- Housing instability encompasses multiple conditions ranging from the inability to pay rent or mortgage, frequent changes in residence including temporary stays with friends and relatives, living in crowded conditions, and actual lack of sheltered housing in which an individual does not have a personal residence.
• Transportation Needs- Unmet transportation needs include limitations that impede transportation to destinations required for all aspects of daily living.
• Utility Difficulties- Inconsistent availability of electricity, water, oil, and gas services is directly associated with housing instability and food insecurity.
• Interpersonal Safety- Assessment for this domain includes screening for exposure to intimate partner violence, child abuse, and elder abuse.

CMS does not require a particular screening tool- as long as it covers all 5 domains, it works. CMS does point readers to the AHC Health-Related Social Needs Screening Tool, which covers all the domains, however, it has 26 questions, which is fairly long. We’ve consolidated a list of other screening tools that not only meet the requirement but are shorter (you can check those out here). 

For SDOH 1 reporting, the denominator is all patients admitted to the hospital who were 18 years or older, and the numerator is of all the patients admitted who filled out the screening form.  For SDOH 2, the denominator is all patients who were screened, and the numerator is the number of those patients who were identified as having a or more social risk factors. 

There are no requirements on the number of patients screened. I repeat, there are no requirements on the number of patients screened. That brings us to a smooth’ish transition to our next topic….

Hospital Commitment to Health Equity (HCHE) Reporting

The goal of the Hospital Commitment to Health Equity measure is not to track how equitable hospital’s care is; it’s simply to understand if the organization has made health equity a strategic priority. That’s because CMS understands that health equity isn’t something that can happen overnight. For both in and outpatient reporting programs, Medicare had the HCHE mandatory first, then a year after the screening became mandatory. A year is still not much time to develop a working program to support the results of the screening… more on that topic coming soon. Now back to HCHE Reporting… it is an attestation measure, and reported annually. It is broken down into 5 domains, and there are multiple elements within each domain. Each domain is worth 1 point for a total of 5 possible points. In order to earn a point for the domain, organizations must affirmatively attest to ALL of the elements within the domain (see domains with all the subcategories, here). 

HCHE Domains

Domain 1: Equity is a Strategic Priority 

Your hospital has a strategic plan for advancing healthcare equity that: 

• Identifies priority populations who currently experience health disparities 
• Establishes healthcare equity goals and discrete action steps to achieving those goals
• Outlines specific resources which have been dedicated to achieving your equity goals
• Describes your approach for engaging key stakeholders, such as community partners. 

Domain 2: Data Collection

Your hospital is actively engaged in 3 key data collection activities: 

• Collecting demographic information, including self-reported race and ethnicity and/or social determinant of health (SDOH) information on the majority of your patients
• Training staff in culturally sensitive collection of demographic and/or SDOH information 
• Inputting demographic and/or SDOH information collected from patients into structured, interoperable data elements using a certified EHR Technology 

Domain 3: Data Analysis 

Your hospital is stratifying key performance indicators by demographic and/or SDOH variables to identify equity gaps and including this information on hospital performance dashboards. 

Domain 4: Quality Improvement

Your hospital participates in local, regional, or national quality improvement activities focused on reducing health disparities. 

Domain 5: Leadership Engagement

Your senior leadership, including your chief executives and your entire hospital board of trustees, demonstrates a commitment to equity through 2 activities:

• Annual review of your strategic plan for achieving health equity
• Annual reviews of key performance indicators stratified by demographic and/or social factors.  

CODE’s Perspective- What We Are Seeing In The Market 

There are many hospitals doing this well- I’m encouraged and inspired by stories I’ve read! There are also many organizations who have been sloppy- those don’t make the headlines, but we need to talk about it. Here’s what we are seeing… let’s start with the screening. People are building out the screening form via the EHR, so this project gets handed off and the project managed by someone in IT. They do a little research, and naturally, the screening tool of choice is  AHC Health-Related Social Needs, because CMS points to it, and the questions and scoring are listed right there in the measure itself. Now who to screen- well, it’s easy(er) to build this out for all patients that are admitted.. And, it seems like the right thing to do anyway. Couple days of head down work to build, then BOOM- it’s live in the EHR! Screening form is available for every patient upon admission, and you can’t discharge/close out the encounter unless it is complete. SDOH 1 & 2- check! Next project- HCHE. Let me google that… no way, there are sooo many templates available! This 1 looks good- 1 hour later, a beautiful PDF outlining the plan, with 1 important change from the template. Domain 2: Collecting demographic information, including self-reported race and ethnicity and/or social determinant of health (SDOH) information on the majority of your patients and all our patients. The IT project manager is feeling lucky- by far the easiest CMS Measure they’ve worked on, and they are doing more than CMS requires by screening every patient admitted! Closes out the project by emailing the plan to the requester, and then goes back to IT land life.

Now, let me tell you what this results in… first comes the process issues. Who is responsible for screening, and when? Is it filled out at time of admission? If yes, and it is an elective patient and we learn from the screening that the patient doesn’t have food to eat when they get home, do we cancel the case? Because obviously the patient not having food when they get home is an issue….? Ummm canceling elective procedures is not a favorable financial move. So the solution is to change the process from screening at admission, to discharge. Financial problem is solved. However, a moral injury problem has been created. Nurses and social workers are very compassionate people, and discharging someone you know has social risks is a gut punch. We’ve also learned that that long 26 question screening tool slows down throughput, whether administered at the beginning or end of the encounter. After a few months, the patients start getting upset- why do you keep asking me this, if you can’t do anything to help me? Process issues, people issues, and patient issues. And now leadership is so busy dealing with that fire, they can’t focus on creating solutions for how to properly handle patients who screen positive. 

My friends, the implementation of a true strategy around SDOH is not a  ‘sprint’. View it as a half marathon. I say half marathon vs marathon with purpose- it’s hard, but the vast majority of people have the ability to do it if they so choose to. First comes committing to it. Then the training- building up the muscle and mental endurance required, over a long sustained period of time, so you don’t hurt.  Over time you see incremental progress, and eventually, you are ready for the race. And after the race, if you choose to commit to the race again, you have a program to follow and know how to do it. 

Conclusion 

CMS is making all hospitals commit to running this proverbial half marathon. CMS is also developing plans and programs to reward hospitals who are doing this well- we’ve seen a preview of this in the Transforming Episode Accountability Model (TEAM). And to be honest, we’re not mad about it. The impact on outcomes is real, the studies are clear, so let’s do the right thing and figure it out. CMS is also giving hospitals a generous amount of time to train, so use it. Take the time to develop a baseline HCHE that is a real plan (not a template pulled from the internet) that is tailored to your organization. Then use that plan to help guide the screening tool selection. Develop processes and systems for screening workflow, and then test them, strategically selecting the sample size. Use the early screening data to get information, then reassess and adjust the HCEH accordingly. Find good community partners. And build up to screening more and more patients, ensuring you can accommodate properly for positive screening. Overtime, you will get to a place that supports screening and managing every patient that you serve.