Screening Questions

Many leading medical practices and providers in North Carolina are interested in more systematically addressing social determinants of health (SDOH). While most practices are not currently conducting routine screening on unmet health-related resource needs, many are beginning to do so and have voiced interest in a standardized approach. DHHS, in partnership with a diverse set of stakeholders from across the state, developed a standardized set of SDOH screening questions.

Resources

SDOH Screening Questions: English, Spanish, Arabic, Chinese (simplified), French, German, Swahili, Vietnamese
SDOH Screening Questions Policy Paper (April 2018)
Field Test Report: Standardized Screening for Health-Related Resource Needs in North Carolina

Design Process

During the summer of 2017 DHHS met with key stakeholders across North Carolina who were interested in, or already working on, initiatives related to SDOH, learning about best practices and supports needed from the Department to continue their work. Following these meetings DHHS conducted a review of best practices related to screening and identifying SDOH and existing screening tools.

From this research DHHS in collaboration with stakeholders identified four priority domains:

  1. Food insecurity 
  2. Housing instability 
  3. Lack of transportation 
  4. Interpersonal violence

In winter 2017-18 DHHS convened a Technical Advisory Group (TAG) made up of diverse subject matter experts and stakeholders from across the state. Together the Department and the TAG came up with a set of design principles for the screening questions, reviewed other SDOH tools and questions and came to consensus on a recommended set of screening questions. Many of the screening questions are modified or adapted from other assessment tools. The collection of standardized questions has not been formally tested as a whole, which may impact validity.

Food: The two questions under this core domain were modified from the validated Hunger Vital sign and are intended to identify food insecurity. 
Housing/Utilities: The first and second questions under this core domain are modified from the Protocol for Responding to Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) assessment tool.  The three questions in this domain are intended to identify individuals who are experiencing homelessness or at risk of losing their housing. 
Transportation: The one question under this domain was adapted from the PRAPARE assessment tool. 
Interpersonal Safety: The first question in this domain was adapted from the PRAPARE assessment tool. The second and third questions were modified from the Humiliation, Afraid, Rape, and Kick (HARK) questionnaire. The questions are related to the exposure of intimate partner violence, elder abuse, and child abuse

In April 2018, DHHS released a policy paper and drafted screening questions. This paper describes the rationale for screening to identify needs related to a person’s social determinants of health, how questions were selected, and how screening will be implemented within Medicaid managed care and encouraged for all populations and in all health and human services settings, regardless of healthcare payor.

In Fall and Winter 2018, DHHS designed and launched a field test to test these standardized screening questions. Field tests were conducted across 18 clinical settings that received Community Health Grants from the North Carolina Office of Rural Health — as well as telephonic case management settings through North Carolina Medicaid‘s primary care management program. Through a multi-phase approach, the field test engaged 804 patients using the standardized screening questions. Combined with 735 responses from clinic staff, these patients were surveyed to gauge impressions of questionnaire length, whether the questions were easy to understand, and overall comfort with asking and answering the questions.

Please find a report on the field test key findings here.

Citations 
Hunger Vital Sign: Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., Cook, J. T., Ettinger de Cuba, S. E., Casey, P. H., Chilton, M., Cutts, D. B., Meyers A. F., Frank, D. A. (2010). Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics, 126(1), 26-32. doi:10.1542/peds.2009-3146.
PRAPARE: National Association of Community Health Centers and Partners, National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Association OPC, Institute for Alternative Futures. “PRAPARE.” 2017.
HARK: Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract. 2007 Aug 29;8:49.

Design Principles

Development of standardized screening questions has been grounded in the following principles:

  1. The screening questions need to include domains where high-quality evidence exists linking them to health outcomes and must identify needs for which there are some resources and services in the community available to address them.
  2. Questions must be simple, brief and applicable to most populations, so they can be easily integrated into workflows in diverse and varied settings across the state. The questions do not have to address all nuances of need. Rather, a positive response on a screening question should trigger a more in-depth assessment that allows for a greater understanding of specific needs and more targeted navigation to resources by a community health worker, care manager, social worker or other member of the team. Since the questions are intended to be used by providers in diverse settings as well as by Prepaid Health Plans (PHPs), there should be flexibility for PHPs or providers to include additional domains as needed or desired by the setting or population being served.
  3. The questions must be validated, drawn from best practices and written at accessible reading levels to ensure they can be effectively used.
  4. To the greatest extent possible, the questions should align with existing screening tools [e.g., Bright Futures Questionnaire, 9 Meaningful Use, Uniform Data Set (Community Health Centers), PRAPARE (Community Health Centers), Accountable Health Community, Pregnancy Medical Home Screen]. This intentional alignment to existing tools will allow for easier implementation and similar data collection.

Timeline

April 2018: Questions released for public comment.

July 2018: Updated screening questions released.

August 2018–Jan 2019: Screening question field testing.

January 2019: Questions available for organizations who wish to incorporate them.

July 2019: Field test report released.

Fall 2019 (launch of Medicaid managed care): PHPs will be required to include screening questions in Care Needs Assessment.

Frequently Asked Questions

1. Are providers required to screen patients with this new tool? 
DHHS has made the screening tool publicly available to providers to utilize in part, or in whole, but, DHHS is not requiring SDOH screening for providers at this time. DHHS strongly encourages practices, providers, social services agencies and community organizations to carry out SDOH screening. Our vision is that the standardized screening questions will be shaped by provider input, become familiar to providers and eventually become part of routine practice workflows statewide.

2. How will PHPs use these screening questions?
In the early implementation of Medicaid Managed Care, the Department will focus on ensuring that the Prepaid Health Plans (PHPs) integrate the questions into their care management approaches. More information on how the SDOH screening questions will be implemented into the “Care Needs Screening” and how this information will be used can be found in the policy paper released by DHHS in April 2018.

3. Why is it important to use these screening questions instead of a different tool?
Standardizing screening questions will help maintain a strong statewide focus on identifying and addressing SDOH. In addition, having consistent screening questions and processes allows for the statewide collection of data on unmet health-related needs of our population and the impact on health outcomes and costs. This valuable feedback loop will inform policy, planning and investment that can support better ways to address unmet resource needs and improve the quality of care in North Carolina.

4. Screening is important to identify people’s needs, but what tools are available to navigate a person to resources? 
Philanthropy, healthcare and community partners came together to invest in NCCARE360 a statewide coordinated care network to electronically connect those with identified needs with community resources – and allow for a feedback loop on the outcome of that connection. This platform has the potential to improve the health of all North Carolinians, including the commercially insured, Medicare, Medicaid, uninsured, military and veteran populations. NCCARE360 is being rolled out across the state now and will be statewide by the end of 2020.