CMS Requirements

Submissions & Reporting

In the Fiscal Year (FY) 2023 Hospital Inpatient Prospective Payment System (IPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) proposed that hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program be required annually to respond to the Hospital Commitment to Health Equity measure. This measure was adopted into the Hospital IQR Program beginning with the Calendar Year (CY) 2023 reporting period / FY 2025 payment determination and for subsequent years. Data entry will be through the QualityNet Secure Portal available to authorized users.

In FY 2023, CMS introduced two new measures for hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program: Screening for Social Drivers of Health Measure and Screen Positive Rate for Social Drivers of Health Measure.

SDOH-1

Voluntary Reporting Period: Reporting is annual, from April 1 through May 15. For CY 2023, reporting is voluntary from April 1, 2024, through May 15, 2024.

Reporting Requirements: Hospitals must report aggregate numerators for both measures and the denominator for the “Screening for Social Drivers of Health” measure.

Web-Based Reporting: Reporting details within the HQR System will be provided closer to the reporting period. For CY 2023, hospitals can report data voluntarily from April 1, 2024, through May 15, 2024.

Documentation by Exception: Documenting “none” when a patient has no issues with HRSNs is acceptable, as long as it reflects that the patient was screened for all five HRSNs.

SDOH-2

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

SDOH-1 & SDOH-2 Measures

SDOH-1 Measure

Description: This measure evaluates whether hospitals screen all patients aged 18 or older at admission for five Health-Related Social Needs (HRSNs)

Numerator: The numerator includes patients aged 18 or older, screened for all five HRSNs, during their inpatient stay.

Denominator: The denominator comprises patients aged 18 or older admitted for an inpatient stay.

Exclusions: Patients who opt-out of screening or are unable to complete it without a caregiver are excluded.

Calculation: The measure is calculated as the number of patients screened for all five HRSNs divided by the total number of eligible patients.

SDOH-2 Measure

Description: This measure provides information on the percentage of patients aged 18 or older, admitted for an inpatient hospital stay, screened for HRSNs, and who screen positive for one or more of the five HRSNs

Numerator: The numerator includes patients aged 18 or older, screened for all five HRSNs, and who screen positive for one or more HRSNs.

Denominator: The denominator comprises patients aged 18 or older admitted for an inpatient stay and screened for all five HRSNs.

Exclusions: Patients who opt-out of screening or are unable to complete it without a caregiver are excluded.

Calculation: The measure calculates five separate rates for each HRSN by dividing the number of patients screening positive for that specific HRSN by the total number of eligible patients screened for all five HRSNs.

Specifications & Calculations

Example Calculation

If 100 patients 18 or older are admitted, with 90 screened for all five HRSNs, the “Screening for Social Drivers of Health” measure would be 90%. The “Screen Positive Rate” is calculated separately for each HRSN.

Time Frame for Screening

Screening can occur at any time during the hospital admission before discharge.

Frequency of Screening

Hospitals should screen during each hospital stay. For frequently admitted patients, hospitals can confirm previous HRSN statuses and inquire about new ones. If captured in the EHR before admission, it can be included in reporting.

Population for Reporting

Discharge date is used to determine the reporting year.

Sampling and Exclusions

CMS requires reporting of all eligible patients, not sampling. Exclusions apply to opt-outs, patients unable to complete screening without a caregiver, and patients who expire during the inpatient stay.

Hospital Commitment to Health Equity Structural Measure Specifications Summary

In addition to the SDOH reporting, hospitals must attest to their commitment to Health Equity.

In the Fiscal Year 2023, CMS introduced a new measure called “Hospital Commitment to Health Equity” for hospitals participating in the Hospital Inpatient Quality Reporting Program. Hospitals need to answer questions related to five different areas to show their commitment to achieving health equity for various groups, including racial and ethnic minorities, people with disabilities, LGBTQ+ individuals, those with limited English proficiency, rural populations, religious minorities, and people facing socioeconomic challenges.

The five domains hospitals need to address are:

  1. Equity as a Strategic Priority: Hospitals must have a strategic plan for advancing health equity, including identifying priority populations experiencing disparities, setting healthcare equity goals, allocating resources, and engaging key stakeholders.
  2. Data Collection: Hospitals should collect demographic and social determinant of health data for most of their patients, provide staff training for sensitive data collection, and use certified technology for data entry.
  3. Data Analysis: Hospitals should analyze data to identify equity gaps, particularly by demographic and social factors, and include this information on performance dashboards.
  4. Quality Improvement: Hospitals should engage in quality improvement activities focused on reducing health disparities at local, regional, or national levels.
  5. Leadership Engagement: Hospital senior leadership, including executives and trustees, should annually review the strategic plan for health equity and key performance indicators stratified by demographic and social factors.

Hospitals receive points for each domain they affirmatively attest to, with a maximum of five points. This measure is part of regular reporting, and hospitals will receive credit for reporting results, regardless of their responses to the attestation questions.

Data Accuracy and Completeness Acknowledgement (DACA)

The DACA serves as an acknowledgment that, at the time of submission, all the information provided by the hospital to the Centers for Medicare & Medicaid Services (CMS) is both accurate and complete. This information includes various aspects such as clinical chart-abstracted measures, patient population and sample counts, HCAHPS survey data, Healthcare-associated infection (HAI) measures reported using the National Healthcare Safety Network (NHSN), Influenza Vaccination Among Healthcare Personnel (HCP) measures reported using NHSN, COVID-19 Vaccination Coverage for Healthcare Providers (HCP COVID-19) reported using NHSN, web-based measures, structural measures, Electronic clinical quality measures (eCQMs), electronic health record data elements for hybrid measures, and the current Notice of Participation.

In essence, hospitals are required to ensure the accuracy and completeness of the data they submit to CMS through this acknowledgment.