UC43: Social Determinants of Health (SDOH) Screener

The Problem

Social determinants (food insecurity, housing instability, transportation barriers, utility assistance, substance use support) affect ~40% of health outcomes but are vastly undertreated. Screening for SDOH is mandated by CMS (quality measure SDOH-screening), but manual administration is time-consuming. Without systematic screening and resource connection, health disparities persist and preventable ED visits/readmissions occur.

What the Agent Does

Agent administers standardised SDOH screening questionnaire (PRAPARE or AHC HRSN) via SMS or patient portal
Uses conversational flow to ask 10 to 15 structured questions: "Are you worried about having enough food?" "Do you have a safe place to sleep?" "Do you have reliable transportation?"
Captures responses and flags positive answers indicating unmet need (e.g., housing instability)
Queries local community resource directory (United Way, Aunt Bertha/findhelp.org, 211.org) for relevant resources
Connects patient to resources: links to food pantries, housing assistance programs, transportation services, financial assistance programs
Generates outreach list for case manager: prioritizes highest-need patients for human follow-up
Tracks whether patient engages with resources (follow-up outreach)

Data Requirements

Primary Data Sources: SDOH screening questionnaires (PRAPARE, AHC HRSN), community resource directories (United Way ALICE database, findhelp.org API, CMS-designated Community Health Centers), patient contact info, social determinant outcome metrics
Classification: PHI/PII (patient identifiers, SDOH screening responses)
Quality Metrics: Screening completion rate >80%; sensitivity for unmet needs >90%; resource matching accuracy >95%; follow-up engagement rate >40%
Complexity: Medium (SMS workflow, questionnaire logic, API integration with resource directories, outreach coordination)
Systems: Epic, Unite Us (community resource platform), Aunt Bertha/findhelp.org

Score Breakdown

Criterion	Weight	Score (1-5)	Weighted
Time Recaptured	15%	4	0.60
Error Reduction	10%	4	0.40
Cost Avoidance	10%	4	0.40
Strategic Leverage	5%	4	0.20
Data Availability	15%	4	0.60
Process Clarity	15%	4	0.60
Ease of Implementation	10%	4	0.40
Fallback Available	10%	4	0.40
Audience (Int/Ext)	10%	3	0.30
Composite	100%		3.80

Why It Scores Well

Regulatory Mandate: CMS quality measure SDOH-screening directly incentivizes deployment (Star Ratings, MIPS)
Health Equity: Addresses documented driver of health disparities; supports DEI objectives
Workflow Integration: Runs outside clinical workflow; no physician burden
Outcome Data: Evidence shows SDOH screening + resource connection reduces readmissions by 10 to 15%
Scalability: Batch processing for entire population possible

Regulatory Alignment

CMS Quality Measures: SDOH-screening is explicit quality measure (eCQM-Medicaid, Star Ratings, MIPS)
CMS Community Health Services: Medicare Advantage plans incentivized to provide SDOH services
Joint Commission: Social needs screening is evolving accreditation expectation
HIPAA: SDOH screening responses are PHI; standard access controls and audit trails required
State Mental Health Parity Laws: No additional requirements (SDOH is not mental health diagnosis)

Sprint Factory Fit

2 to 3 sprints (questionnaire workflow design, community resource directory integration, case manager interface, compliance review)

Sprints Required: 2 to 3 sprints (questionnaire workflow design, community resource directory integration, case manager interface, compliance review)
Timeline: 4 to 6 weeks from requirements to pilot
Governance: Care management director review of questionnaire and resource matching; audit resource accuracy monthly
Success Metrics: Screening completion >80%; resource engagement >40%; readmission reduction >10%; case manager satisfaction >4.0/5

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