Hero Image

Repisodic Blog

Sharing insights, impact and successes in our mission to help health systems discharge every patient.

Social Drivers of Health: New Reporting Requirements for the Hospital Inpatient Quality Report Program


In a significant move toward patient-centered care, the Centers for Medicare and Medicaid Services (CMS) has mandated that hospitals reporting to the Inpatient Quality Reporting (IQR) program submit two brand new measures: SDOH-1 and SDOH-2. These measures are voluntary in 2023 and required in 2024.

The Goals of the New Measures

Recognizing the profound impact of social drivers of health (SDOH) on patient well-being, these measures have a twofold purpose. Firstly, they emphasize the screening of social risk factors, aiming to identify patients at risk. Secondly, they encourage collaboration between healthcare providers and community-based organizations, forging a path toward holistic patient care.  

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 for longer periods of time. Unfortunately, social risk factors disproportionately impact underserved communities.  These new measures establish a screening for social risk factors and provide a rate of your inpatient population who were identified as having one or more of these social risk factors.  By systematically screening for social risk factors, hospitals can bridge the gap between clinical treatment and community resources. This, in turn, empowers healthcare professionals to address not only medical needs but also the broader social determinants that shape health outcomes.  

Beyond enhancing patient care, these measures also hold the promise of alleviating clinician burnout. Acknowledging and addressing patients’ social needs that contribute to adverse health outcomes could streamline treatment strategies and simplify discharge planning for healthcare providers.

How the Measures are Scored

There are two measures: SDOH-1, Screening for Social Drivers of Health and SDOH-2, Screen Positive Rate for Social Drivers of Health. SDOH-1 focuses on the number of patients screened, while SDOH-2 hones in on the rate of positive screenings among those screened. The Health-Related Social Needs (HRSN) framework forms the basis for screening, encompassing the five below-mentioned domains.

The 5 Domains of SDOH Screening

1. Food Insecurity: Food insecurity is defined as limited or uncertain access to adequate quality and quantity of food at the household level.

2. 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.

3. Transportation Needs: Unmet transportation needs include limitations that impede transportation to destinations required for all aspects of daily living.

4. Utility Difficulties: Inconsistent availability of electricity, water, oil, and gas services is directly associated with housing instability and food insecurity.

5. Interpersonal Safety: Assessment for this domain includes screening for exposure to intimate partner violence, child abuse, and elder abuse.

How CMS is Expecting Hospitals to Collect and Report the SDOH Measures

CMS has intentionally allowed flexibility in data collection methods, enabling hospitals to tailor screenings according to their context. The AHC Health-Related Social Needs Screening Tool offers a guideline for creating patient surveys. Data collection can stem from administrative claims, electronic clinical records, patient assessments, or surveys.

CMS also acknowledges that this data could come from multiple sources: administrative claims data, electronic clinical data, standardized patient assessments, or patient-reported data and surveys.  Hospitals must report these measures once annually using the web-based data collection tool within the HQR (Hospital Quality Reporting) system online. 

When submitting to the HQR, the SDOH-1 requires reporting the denominator (number of inpatients) and the numerator (the number screened). SDOH-2 then requires hospitals to submit a rate for all five domains.

While CMS has not officially released the submission deadline, in the final rule they said it would follow the same submission schedule as the other structural measures.  Based on previous reporting years, the schedule is most likely to work like this: 

Voluntary reporting

  • Collection period: January 1, 2023 – December 31, 2023
  • Submission deadline: May 15, 2024

Required reporting

  • Collection period: January 1, 2024 – December 31, 2024
  • Submission deadline: May 15, 2025

Get Help Now Before SDOH Measures are Required!

If you don’t want to navigate the new Social Drivers of Health measures alone, Repisodic can help. Our platform – combined with the expertise of our regulatory team – gives you an EHR-embedded toolset built directly into your workflow with the power to collect and report your data to meet 2023’s requirements and beyond.  Get in touch with us today to learn more!