CMS vs TJC Health Equity Requirements

How to Juggle Your Hospital’s Health Equity Requirements

Save time and headaches on your CMS health equity + SDOH measures, as well as The Joint Commission health equity standard, with these 6 tips.

Wondering how your hospital or healthcare system will juggle all your new health equity measures and requirements in 2023 and 2024? Fear not: Medisolv is here to help you make sense of the very-necessary-madness. We’ve combined all of CMS’s and The Joint Commission’s latest health equity requirements into one quick and easy guide to help you organize your team’s efforts strategically and efficiently.

What are My Health Equity Requirements?

All in all, there are 6 new requirements you need to meet over the next 2 years. Some are easy, some have a lot of moving parts. Almost all of them have overlaps that you can take advantage of so that you’re not duplicating efforts.  

We’ve color-coded the 6 requirements throughout this post to help you track each one as we cover it. Pay close attention to CMS’s HCHE measure and TJC’s LD.04.03.08 standard—both are broken down into a series of sub-requirements, so you’ll see them pop-up multiple times as you start to build your health equity requirements task list.






CMS Requirements

HCHE:   Hospital Commitment to Health Equity Measure

NEW Process Measure with 5 Domains




SDOH-01: Screening for Social Drivers of Health Measure

NEW Structural Measure (Medisolv calculates this as an eCQM)




SDOH-02: Screen Positive Rate for Social Drivers of Health Measure

NEW Structural Measure (Medisolv calculates this as an eCQM)



TJC Requirements

Standard LD.04.03.08: Reducing Health Disparities


NEW Standard with 6 Elements of Performance (EPs)




Standard RC.02.01.01 EP25: Collecting Race & Ethnicity Data

Existing EP for hospitals

NEW EP for critical-access hospitals and others




Standard RI.01.01.01 EP29: Prohibiting Discrimination

Existing EP for hospitals

NEW EP for critical-access hospitals and others




We then combined all of these requirements into 6 essential tasks. We’ve arranged them in an order we think makes sense, but we suggest reviewing all of the tasks and then deciding on a chronology that works for you.

We also recommend reading our detailed guides on CMS’s HCHE measure, CMS’s SDOH measures, and TJC’s Standard LD.04.03.08 to make sure you’re fully up to speed on all your health equity requirements. 

HRSN versus SDOH: A Quick Disclaimer

Before we dive into the task list, it’s important to note that TJC uses the term health-related social needs(HRSN) in its requirements language, instead of CMS’s preferred (and interchangeable) terms, social determinants of health (SDOH) and social drivers of health (SDOH). To make your life easier, we’ll use the term SDOH throughout this guide. Now let’s get into that task list!

Task #1: Kill Two Requirements with One Action Plan

Both CMS and TJC require you to have a written plan for addressing health equity. The thing to do here is to sit your team down and draft a single plan that combines each requirement’s demands, of which there is a ton of overlap.

Keep in mind that CMS gives you the power to identify your “priority populations,” while TJC more explicitly states that you have to address “at least one” known disparity in your system. So you have the flexibility to focus your plan only on the priorities that make sense (and are manageable!) for your team right now. 

CMS HCHE Measure
Domain 1: Action Plan

TJC Standard LD.04.03.08
EP4: Action Plan

Identify “priority populations” who currently experience health disparities

Identify “at least one health disparity” and the patient population of focus

Establish goals for improvement

Establish goals for improvement

Outline “discrete action steps” and “specific resources” for achieving those goals

Outline “strategies and resources” for achieving those goals

Describe your approach for engaging key stakeholders, such as community partners 

Not specifically required

Not specifically required

Create a system for monitoring and reporting your progress


Task #2: Start Screening Your Patients Strategically

This set of screening requirements may be the biggest overhaul to your system, so once you’ve a draft of your plan in place, it probably makes sense to start here.

With CMS’s two new SDOH measures, you will need to (1) screen ALL of your admitted patients, ages 18 and older, for 5 mandated SDOH factors and (2) track how many of those patients screen positive for at least one of those SDOH factors by 2024. Both measures are voluntary this year.

Fortunately, TJC’s screening requirement, which is mandatory in 2023, is a great starter tool. TJC is giving you the flexibility to screen all your patients or just a sampling of patients by as many or as few SDOHs as you want.

Plan your approach to TJC’s mandate strategically so that you’re ready for CMS in 2024. For example, you can assess just a sampling of patients using CMS’s 5 required SDOH factors to meet TJC’s mandate now, then expand that assessment to all patients in 2024.  

CMS SDOH-01 & SDOH-02 Measures: Screenings

TJC Standard LD.04.03.08:
EP3: Screenings

Screen all patients 18 and older for a pre-determined list of 5 social factors 

Screen all patients—or a sampling of patients—for your choice of social factors

Report your positive screen rate

Provide interventions for patients that screen positive

Voluntary in 2023
Mandatory in 2024

Mandatory in 2023


Task #3: Capture Patient Race/Ethnicity Data (at Minimum) in Your EHR

While you may be screening for a whole host of new factors, you can easily satisfy your electronic data capture requirements for both TJC and CMS by collecting only race and ethnicity data within a patient’s EHR (for now). CMS also wants you to attest that you are training staff on how to collect this data in a culturally sensitive way.

CMS HCHE Measure
Domain 2: Data Collection

TJC Standard RC.02.01.01
EP25: Data Collection

Collect demographic information, including self-reported race and ethnicity and/or SDOH information on the majority of your patients 

The medical record contains the patient’s race and ethnicity

Input data into structured, interoperable data elements using a certified EHR technology 

Train staff in culturally sensitive collection of demographic and/or SDOH information


Task #4: Choose a Small Selection of Data to Stratify

While both TJC and CMS now require you to stratify your data, they’re both very flexible in how you go about doing this. You get to choose which data sets you want to examine and which demographic/SDOH lenses you examine them through. Start small, then expand your data sets or your demographic/SDOH variables as you get more comfortable with process.

Also, don’t overlook the fact that CMS wants you to take this one step further and attest that you’re sharing your stratified data on your performance dashboard.

CMS HCHE Measure
Domain 3: Data Stratification

TJC Standard LD.04.03.08
EP3: Data Stratification

Stratify “key performance indicators” by “demographic and/OR SDOH variables”

Stratify “quality and safety data” using “sociodemographic characteristics” 

Include this information on hospital performance dashboards


Task #5: Schedule an Annual Review at Minimum

If you’ve created your action plan correctly, you should have a clear system for reporting your progress. At a minimum, both bodies want you to review your plan and your progress with your leadership team once a year to ensure it remains an active organizational priority.

CMS HCHE Measure
Domain 5: Leadership Engagement 

TJC Standard LD.04.03.08
EP6: Communicate Your Progress  

What: Annual review (at minimum) of your “strategic plan” and “key performance indicators”

What: Annual update (at minimum) on “progress to reduce health care disparities” 

Who: Senior leadership including C-suite & hospital board

Who: Key stakeholders including leaders, licensed practitioners, and staff


Task #6: Make Sure You’ve Covered the Additional Requirements

Each of these are fairly straightforward attestation/documentation requirements. Once you’ve crossed these off your task list, you can officially say you’re health equity requirements for this year are done!


Requirement it Satisfies


Appoint a health equity leader

TJC Standard LD.04.03.08

EP1: The organization designates an individual(s) to lead activities to reduce health care disparities for the organization’s patients.

Address goals that aren’t met

TJC Standard LD.04.03.08

EP5: The organization acts when it does not achieve or sustain the goal(s) in its action plan to reduce health disparities

Engage in community efforts

CMS HCHE Measure

Domain 4: Your hospital participates in local, regional, or national quality improvement activities focused on reducing health disparities

Prohibit discrimination

TJC Standard RI.01.01.01

EP29: The organization prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity/expression.


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? Check out these resources to learn more, or contact us to schedule a 1:1 info session.



Erin Heilman

Erin Heilman is the Vice President of Marketing for Medisolv, Inc. She has led Medisolv’s marketing team for the better part of a decade, developing content to assist healthcare quality leaders understand their regulatory requirements. She has led the marketing team in developing successful healthcare strategies to enhance the company brand and meet business goals. Erin is a Leapfrog Certified Coach.

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