Complete guide to Social Determinants of Health (SDOH) screening for US hospitals — screening tools, ICD-10 Z-codes, community resource referrals, CMS requirements, and SDOH software.
SDOH accounts for 80% of health outcomes — yet most US hospitals don't screen for them. CMS now requires SDOH screening in value-based care programs. This guide covers everything you need.
SDOH Screening Domains
| Domain | Screening Question | ICD-10 Z-Code |
|---|---|---|
| Housing | Do you have stable housing? | Z59.0 (homelessness), Z59.1 (inadequate housing) |
| Food insecurity | Within the past 12 months, did you worry food would run out? | Z59.4 (food insecurity) |
| Transportation | Do you lack transportation to medical appointments? | Z59.8 (transportation insecurity) |
| Utilities | Can't afford electricity, water, gas? | Z59.3 (utility insecurity) |
| Financial | Do you have income to meet basic needs? | Z59.5 (extreme poverty) |
| Education | Do you have less than high school education? | Z55.0 (illiteracy) |
| Social isolation | Are you frequently alone or lonely? | Z60.2 (social isolation) |
| Safety | Do you feel unsafe at home? | Z69.9 (exposure to violence) |
SDOH Screening Workflow
- Screen at intake: Administer SDOH screening during patient registration or annual wellness visit
- Document Z-codes: Record ICD-10 Z-codes for identified social needs
- Risk stratify: Categorize patients by number and severity of social needs
- Refer to resources: Connect patients to community resources (food bank, housing, transport)
- Track referrals: Monitor whether patient connected with community resource
- Follow-up: Re-screen at next visit to assess if needs were addressed
- Report to CMS: Include SDOH data in value-based care reporting
CMS SDOH Requirements
- MIPS 2026: SDOH screening is a MIPS improvement activity (up to 10 points)
- ACO REACH: ACOs must screen for SDOH and address social needs
- Hospital VBP: SDOH screening included in health equity measures
- Medicaid waivers: States can use Medicaid funds for SDOH interventions
- CHNA: Hospital Community Health Needs Assessment must address SDOH
Frequently Asked Questions
- What are Social Determinants of Health (SDOH)?
- SDOH are non-medical factors that affect health outcomes — housing, food security, transportation, education, income, social support, and safety. They account for 80% of health outcomes, while medical care accounts for only 20%. CMS requires hospitals to screen for SDOH in value-based care programs.
- What are ICD-10 Z-codes for SDOH?
- ICD-10 Z-codes (Z55-Z65) document social determinants in medical records: Z59.0 (homelessness), Z59.4 (food insecurity), Z59.8 (transportation insecurity), Z60.2 (social isolation), Z63.4 (caregiver burden). Documenting Z-codes enables tracking and addressing SDOH.
- What SDOH screening tools do US hospitals use?
- Common SDOH screening tools: PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences), Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool, and Social Needs Screening Tool from American Academy of Family Physicians.