How NCQA Created Measures on Social Determinants of Health Screenings

It’s hard to improve what isn’t measured, the adage goes. At NCQA, newly proposed HEDIS measures look to address that problem in the realm of social determinants of health screenings.

HEDIS measures, or Healthcare Effectiveness Data and Information Set measures, set out to help healthcare providers and payers to understand their current performance in key areas and plan quality improvement efforts. HEDIS measures can encompass a number of different healthcare processes and quality areas, and most recently NCQA, the body governing HEDIS measure development, is zeroing in on social determinants of health.

“We can't address needs that we don't know exist,” Rachel Harrington, PhD, a research scientist at NCQA, said in an interview. “Having a metric that identifies social needs provides information that is necessary to begin to address the barriers to pursuing health for patients and individuals.”

The healthcare industry has been on the path toward measuring SDOH screenings for some time, Harrington added. Although public health experts have been flagging social determinants of health as critical for some time, the movement toward value-based care has brought those social factors to the center of the conversation. After all, healthcare payers and providers can’t achieve good outcomes if they don’t address the social factors affecting patient health and wellness.

“There's a broad body of evidence at this point that tells us that somewhere between 30 to 50 percent of health outcomes, depending on the study that you look at, goes back to the social determinants and of health and social needs that a person is experiencing,” Harrington said. “As we think about this, for our healthcare system to really be effective and to actually improve health outcomes, we can't afford to ignore this. It's too important.”

“What's really important now and really motivating now is that the healthcare system is really starting to build momentum in this space,” she continued. “You're seeing state and federal payers having built ways for health plans to provide support and actually put money into action. You are also seeing health systems on the ground, really seeing the importance and the value of engaging with the communities that they're working in and engaging with how people are living and experiencing their lives.”

For many healthcare organizations, that realization has translated to health equity and social determinants of health work. Take, for instance, the clinician treating a patient with diabetes. Providers understand that if that patient struggles with food security, it will limit her ability to improve her condition. Referrals to food pantries serving nutritious foods could help close the outcomes gap.

But before the patient and the provider can get to that referral, the healthcare organization first needs to screen that patient to even detect that social need. That screening process is getting formalized, with some organizations integrating paper screenings into patient intake while others digitize the process to interoperate with the EHR.

That’s where NCQA comes in. In newly proposed HEDIS measures, for which NCQA is accepting public comment until March 11, 2022, the organization is looking to understand how effective an organization’s social determinants of health screening is.

“We started off focusing on the first question: are you screening?” Harrington recounted. “Who are you screening? How are you reaching out and understanding your population?”

But through its measure development process, NCQA determined there was more depth to SDOH screening. NCQA begins its measure development process by reviewing the evidence base of quantitative data, allowing it to loosely frame what it posits could be an effective and comprehensive approach to quality improvement measures.

But NCQA supplements the quantitative with qualitative stakeholder focus groups, Harrington added, which allowed it to dig deeper on its questions simply about whether organizations are conducting SDOH screenings. That led NCQA to the second part of its proposed HEDIS measures about whether SDOH screening results in social services referrals.

That leaves two key HEDIS measure proposals:

• Percentage of members who were screened for unmet food, housing, and transportation needs
• Percentage of members who received a corresponding intervention if needed

These proposed measures may zero in on three key social determinants of health—food, housing, and transportation needs—but Harrington emphasized this is not the full breadth of social issues affecting health and wellness.

“Food, housing, and transportation—that certainly isn’t the full portfolio of social needs,” Harrington noted. “We know there are others that are critically important as well, such as economic security, or interpersonal violence typically comes up as well.”

But again, it was NCQA’s robust measure development process that signaled these three common SDOH were a good place to start.

“We started with those three by doing a review of the literature of the evidence in the space,” Harrington continued. “And then also trying to look at where the data standards and the screening questionnaires, the infrastructure, per se, was mature enough to support a standardized, consistent quality metric.”

For example, Harrington and team carefully considered where there were existing data standards that make SDOH screening and measurement a realistic goal.

“From very early on, we also started looking at what the health IT data standards look like,” Harrington stated. “Because one of the things you think about when you're developing a quality measure is where your data is going to come from, who has access to it, who needs access to it, and what's it going to take to collect and share it?”

Those questions are key in a burgeoning domain like SDOH screening; there are a number of new screening tools, even homegrown paper surveys, that organizations are leveraging. Organizations might ask questions differently than others, depending on the culture of their patient populations, or maintain different record-keeping processes.

And that variation gets compounded when considering the number of provider organizations interested in doing this work. A single patient might answer three different SDOH screenings from her primary care provider, her cardiologist, and her endocrinologist. Her health plan may chime in, too, highlighting a duplicative system.

“We started looking at the health IT data standards that supported interoperability, supported data sharing, supported consistent collection and use of this information,” Harrington said. “And that really shaped a lot of our thinking on this measure.”

As it turns out, there are well-developed standards for SDOH data pertaining to food, housing, and transportation, something that influenced NCQA’s decision to focus on those particular social needs.

As healthcare professionals continue to develop tools to support work on other social determinants, like interpersonal violence or educational attainment, there could be room to assess those as part of a HEDIS measure, an area Harrington indicated NCQA would consider.

But in the near future, NCQA is looking to close the loop on its current measure development process with its public comment period. According to Harrington, the public comment period allows NCQA to evaluate how proposals will work in practice by listening to a broad range of experiences.

“The public comment is a really critical opportunity, for us and for the larger health and equity community, to bring together the perspectives on this. It's core to all of our measure development,” Harrington said.

“It's part of a process for any measure that we work on to ensure the validity and make sure the measure is doing what it needs to do,” she concluded. “It makes sense, it's meaningful, it's practical, but for this measure, in particular, it’s key to acknowledging it's an evolving space that different groups may be in very different places in terms of where they are collecting or using this information.”