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How to Build Your SDOH Screening Process


If you’re ready to build your hospital’s SDOH screening process—but you’re not sure where to start—you’ve come to the right place.


Jodie Franzen
Director of Performance Excellence
Duncan Regional Health

We sat down with Jodie Franzen, director of performance excellence at Duncan Regional Health in Duncan, Oklahoma to hear how her team built and implemented a comprehensive SDOH screening process that’s both valuable on a patient care level and fully compliant with CMS’s two new SDOH measures.  

And guess what we learned? Getting your SDOH screening tool up and running may be easier than you think. You just have to be a little “resource”ful.

What motivated you to get a jump start on your social determinants of health (SDOH) screening process? Was it pressure from CMS with its new SDOH measures?

Jodie: We have been trying to get a handle on health equity and social determinants of health [SDOH] for some time now. In 2018, we started using our Medisolv data in ENCOR to develop a DEI annual report, separating out our patient care data by race, ethnicity, and gender. It was good way to begin looking for areas we could improve on. Then, when CMS started talking more about introducing social determinants of health measures, I knew it was time to start expanding beyond those variables and build an SDOH screening process into our data and our workflow.

Who did you work with to get the SDOH screening project off the ground?

Jodie: There were three of us: me, our chief nursing officer, and our head of social work and case management. I knew our social work team had been thinking about these issues for a long time and already understood on a qualitative level where we have challenges.  

How did you develop your SDOH screening questions?

Jodie: We kept it simple! When I saw the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool that CMS had developed, I sent it to our little working group and said, ‘This is what CMS is going to start asking. Let’s start with these.’ We were all in agreement, so we went ahead and started building them in our EHR, Meditech, right away. We figured we could always change the questions; we just needed a place to start. So far, though, it's working for us.

[Editor’s note: the ACH HRSN Screening Tool includes 10 recommended questions covering all 5 CMS-mandated social drivers of health under SDOH-01 and SDOH-02, as well as a host of supplemental questions. You can find it online here.]


Did you use CMS’s actual phrasing for each question?

Jodie: Pretty much. We pulled it directly CMS, down to the opt-out language.

Once you had your SDOH screening questions, how long did it take to build them into your workflow and your EHR?

Jodie: Honestly, only about a week. I started by working with our head of case management because her team would be handling much of our inpatient side. Once I got that built, I moved on to the areas I knew her team didn’t cover but that we wanted to focus on: our birth center, our joint replacement center, and our critical access hospital.

At each location, I consulted with the nurse navigator or supervisor to figure out where to put the questions, and in each instance we agreed the admissions assessment made sense. As the nurse or social worker performs the screening, they’re inputting the responses directly into our EHR. Our nurses and social workers do so many other screenings—it’s really just part of the overall screening process now.

Do you plan to expand the SDOH screening to other areas of your health system?

Jodie: Yes, I want to make sure we’re fully ready for our Joint Commission [TJC] survey as well, so we’ve already begun adding the SDOH screening to our outpatient rehab center and geriatric psychiatry day program, both of which fall under our TJC purview. Those are going live right now. And we definitely want to roll this out to our clinics because we would get a lot of data—but that’s going to be a much bigger project!

So, across the board, you do the SDOH screening at admission. Do you ask the questions again at any other time?

Jodie: Typically, with an inpatient encounter, no, because the patient’s answers don't really change from intake to discharge. But for our geriatric psychiatry program, that is something we may consider because those patients are in that program for months at a time, so their SDOH status could change. When we launch this in our clinics, I’m sure the screening is something we’d want to repeat at least annually for each patient.

What pushback have you received from staff – if any?

Jodie: The biggest challenge has been that staff don’t want to ask the questions unless they feel confident they can follow through on them. I wouldn't call it pushback; they all think it’s important information and they wanted to ask these questions. But they were nervous. Healthcare people don't want to collect information if they can't help. If a patient screens positive for no transportation or no food, you have to be able to do something.

How have you addressed their “positive screening” anxiety?

Jodie: We’ve developed a resource page for our staff. It’s a list of resources, like food banks and transportation options, available in community. A nurse can hand it to a patient and walk the patient through it. We made a separate resource page for our critical access hospital, which is 35 miles away.

We want to expand the SDOH screening to our clinics because that will give us really great data, but we are not going to even consider making that move until we have resource lists for them. And it’s a bit more complex because our clinics are in so many different locations. So, we’ve got to make resource lists that are customized to what’s accessible and convenient to each location. But we know staff are going to feel very hesitant to make this move without that kind of support tool.


Are you following up with patients in any way to see if they’re connecting with the resources you give them?

Jodie: Right now, handing over the resources page is the last step for us. We want to start building connections with some of the resources that we’re referring people to so that we will eventually be able to do that kind of follow-up. We’re lucky in that our hospital is non-profit and has a separate foundation in place, called Pathways to a Healthier You, that’s already very connected to the community. I’m hoping they can help us build up partnerships with these resources.

Did you have to train your staff on how to sensitively approach the SDOH screening questions with patients?

Jodie: Nursing didn’t ask for any training. They were already, on some level, talking with patients about these types of issues. We’ve been doing safety screenings for years, so these questions didn’t feel that new or difficult to them. 

Our outpatient rehab center was different because it’s all therapists. It was harder for them, so they asked our head of case management for some scripting on how to initiate the screening process to the patient, which she provided.

You have been using Medisolv’s new ENCOR Equitable Care Module to calculate your SDOH measures and begin stratifying your existing eCQMs. What has your SDOH data revealed so far?

Jodie: We’ve been talking about SDOH for years, and so far the data has confirmed exactly what we suspected: transportation is our biggest issue. Of course, it’s also the hardest issue for us to address. There are no Ubers here, no public transportation system. There are two or three grant-funded services, but you have to call them at least three days in advance, and they’re not wheelchair-friendly. It will be interesting to see what CMS does with this data because there are many roadblocks to good health that are out of a hospital’s control.

But I’ve really liked having the data stratification, because it’s helped us identify things we didn’t know going in, namely that our Hispanic patient population ranks slightly higher on utilities, housing, and food insecurities. It’s made us—including our CEO—start thinking on a more tactical level about what we can do to help. We’re thinking now about putting a food pantry in our hospital and adding a clinic in our predominantly Hispanic service area.

Are you planning to submit the voluntary SDOH measures this year?

Jodie: Yes, we’d like to. We’ve got it going in our ENCOR platform with Medisolv as you mentioned. We wanted to get started as early as we could to see what the data looks like and be ready to turn it in when it’s mandatory.

You definitely have a healthy head start on your SDOH screening measures. What advice do you have for other healthcare systems that are trying to figure out where to start?

Jodie: Start working on a list of resources that you can give to patients who screen yes while you’re developing your SDOH screening process. Your teams are going to be afraid to ask the SDOH screening questions if they don’t have some way to help out when a patient screens positive. Fair warning: those resources are probably going to be limited. Try to accept that fact and just identify what you can do to support them. It’s at least one step in the right direction.

About Duncan Regional Health

Duncan Regional Health in a not-for-profit regional health system serving Stephens and Jefferson counties in Oklahoma. The system includes two hospitals and 20 provider clinics that offer a variety of specialty practices, including cancer, wound, and cardiac care.

MEDISOLV's NEW Equitable Care Module CAN HELP 

Did you know that our ENCOR platform’s new Equitable Care Module lets you stratify your data and fulfill today’s health equity measure requirements with unprecedented speed? We've turned the SDOH structural measures into eCQMs for you so you don't have to come up with a brand new way of reporting. Check out these resources to learn more, or contact us to schedule a 1:1 info session.

Get more helpful SDOH tools now:



Erin Heilman

Erin Heilman is the Vice President of Marketing for Medisolv, Inc.

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