Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31

Description:
The percentage of persons who were screened using prespecified instruments for unmet food, housing and transportation needs at least once during the measurement period, and the percentage of persons with a positive screen for food, housing or transportation who received an intervention corresponding to the positive screen within 30 days.

Stratifications: 
Age as of the start of the measurement period.

• ≤17 years.
• 18–64 years.
• 65 years and older. 

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS.

Initial Population:

• Measure Item Count: Person. 
• Age: 0+ years of age as of the start of the measurement period.
• Benefits: Medical.
• Continuous Enrollment: The measurement period.
• Allowable gap: No more than one gap of ≤45 days during the measurement period. No gaps on the last day of the measurement period.  

Definition: 
Interventions: An intervention corresponding to the type of need identified on or up to 30 days after the date of the first positive screening during the measurement period.

• A positive food insecurity screen finding must be met by a food insecurity intervention.
• A positive housing instability or homelessness screen finding, must be met by a housing instability or homelessness intervention.
• A positive housing inadequacy screen finding must be met by a housing inadequacy intervention.
• A positive transportation insecurity screen finding must be met by a transportation insecurity intervention.

Interventions may include assistance, counseling, coordination, education, evaluation of eligibility, provision or referral.

Food insecurity: Uncertain, limited or unstable access to food that is adequate in quantity and in nutritional quality, culturally acceptable, safe, and acquired in socially acceptable ways.

Housing instability: Currently consistently housed, however may have experienced any of the following circumstances in the past 365 days: being behind on rent or mortgage, multiple moves, cost burden or risk of eviction.

Homelessness: Currently living in an environment that is not meant for permanent human habitation (e.g., car, park, sidewalk, abandoned building, on the street), not having a consistent place to sleep at night; or because of economic difficulties, currently living in a shelter, motel, temporary or transitional living situation.

Housing inadequacy: Housing does not meet habitability standards.

Transportation insecurity: Uncertain, limited or no access to safe, reliable, accessible, affordable and socially acceptable transportation infrastructure and modalities necessary for maintaining one’s health, well-being or livelihood.

Screening Instruments

Food insecurity screening instruments

Eligible screening instruments with thresholds for positive findings include:

1Proprietary; may be cost or licensing requirement associated with use.

 

Housing instability, homelessness and housing inadequacy screening instruments

Eligible screening instruments with thresholds for positive findings include:

 

¹Proprietary; may be cost or licensing requirement associated with use.

 

Transportation insecurity screening instruments

Eligible screening instruments with thresholds for positive findings include:

 

¹Proprietary; may be cost or licensing requirement associated with use.

Note: NCQA recognizes that organizations might need to adapt or modify instruments to meet the needs of their membership. To clarify:

• The SNS-E measure specification does not prohibit cultural adaptations or linguistic translations from being counted toward the measure’s screening numerators.
• Only screenings documented using the LOINC codes specified in the SNS-E measure count toward the measure’s screening numerators.
  

The Regenstreif Institute, which maintains the LOINC database, has indicated that LOINC codes are not developed at the level of granularity that distinguishes between original and adapted or translated instruments.

Denominator:

Denominators 1, 3, 5: The initial population minus denominator exclusions.
Denominator 2: All persons in numerator 1 with a positive food insecurity screen finding, between January 1 and December 1 of the measurement period.
Denominator 4: All persons in numerator 3 with a positive housing instability, homelessness or housing inadequacy screen finding, between January 1 and December 1 of the measurement period.
Denominator 6: All persons in numerator 5 with a positive transportation insecurity screen finding, between January 1 and December 1 of the measurement period.

Numerator:

Numerator 1—Food Screening
Persons in denominator 1 with a documented result for food insecurity screening performed between January 1 and December 1 of the measurement period.

Note: Food Insecurity Screening Item Response Exception: Credit for screening occurrence is given when documentation of a non-null response for a given screening item exists. There is one exception for Food Insecurity Screening Item in Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences [PRAPARE]®1 (LOINC 93031-3). Given the structure of this question, a null response is considered a valid negative screen result. Therefore, a null result is considered a valid response to screening item LOINC 93031-3. All other screening items require a non-null response to meet numerator 1.

Numerator 2—Food Intervention
Persons in denominator 2 who received a food insecurity intervention on or up to 30 days after the date of the first need identified or positive food insecurity screen (31 days total).

Numerator 3—Housing Screening
Persons in denominator 3 with a documented result for housing instability, homelessness or housing inadequacy screening performed between January 1 and December 1 of the measurement period.

Numerator 4—Housing Intervention
Persons in denominator 4 who received an intervention corresponding to the type of housing need identified on or up to 30 days after the date of the first housing need identified or positive housing screen (31 days total).

• Housing Instability Intervention
• Homelessness Intervention
• Housing Inadequacy Intervention

Numerator 5—Transportation Screening
Persons in denominator 5 with a documented result for transportation insecurity screening performed between January 1 and December 1 of the measurement period.

Numerator 6—Transportation Intervention
Persons in denominator 6 who received a transportation insecurity intervention on or up to 30 days after the date of the first transportation need identified or positive transportation screen (31 days total).

Summary of changes

• Removed the definitions of “participation” and “participation period.”
• Added provider assessments to the screening numerators 1, 3 and 5.
• Added an additional method for identifying positive needs in denominators 2, 4 and 6.
• Removed health risk and behavior assessments from interventions in numerators 2, 4 and 6.
• Added community health integration service and principal navigator service codes to the intervention numerators.
• Removed the age requirement for exclusion of Medicare enrollees in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
• Removed the SSoR exclusions data elements from the data element tables.
• Technical Update: Revised the description, guidance, Interventions definition, denominator 2, 4 and 6, and numerator 1, 3 and 5.

Best Practice and Measure Tips

• The screening tool must be dated and scored by the provider.
• The measure looks for the first positive screening. Compliance for the “follow-up” is controlled by the first positive screen in the MY. If the follow up is noncompliant, the member will remain noncompliant unless an earlier positive screen with an intervention is found.
• Compliant Interventions can come from the same visit as the positive screen.
• Ensure the patient has sufficient time, a comfortable environment, and privacy to talk about their social needs.
• Encourage your patients to share their social needs. They might need a gentle prompt to discuss non-medical issues with their healthcare provider.
• Clarify the screening's purpose to the patient and provide support and resources as needed.
• Inform your staff about the significance of screening, recording, and coding patients' social needs.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who die any time during the measurement period.
• Medicare enrollees in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
  
  

Measure Codes

Food Insecurity Procedures

• CPT: 97802, 97803, 97804
• HCPCS: G0019, G0022, G0023, G0024, G0140, S5170, S9470
• SNOMED CT US Edition*

Housing Instability Procedures

• HCPCS: G0019, G0022, G0023, G0024, G0140
• SNOMED CT US Edition*

Homelessness Procedures

• HCPCS: G0019, G0022, G0023, G0024, G0140
• SNOMED CT US Edition*

Housing Inadequacy Procedures

• HCPCS: G0019, G0022, G0023, G0024, G0140
• SNOMED CT US Edition*

Transportation Insecurity Procedures

• HCPCS: G0019, G0022, G0023, G0024, G0140
• SNOMED CT US Edition*

*Please note that SNOMED CT US Edition codes are not listed here. For access to the complete set of codes related to SNS-E measure, contact your Provider Engagement Liaison or email [email protected].