How to Measure Health Equity: A Guide for Hospitals

How to measure health equity: it’s the billion-piece puzzle that every healthcare leader is trying to solve right now. But the solution to measuring health equity is anything but obvious.There are countless social variables at play, new CMS health equity requirements to juggle, and (as always) limited hospital resources to work with.

But we should and we must start somewhere. In this post, I’ll walk you through the basics: the key terminology you need to know, which CMS measures you need to track, and 5 essential tips for figuring out how to measure health equity in your hospital.

Which health equity measures to track

We have written extensive guides on how to set up each of CMS’s three new health equity measures, but in case you need a quick refresher of which measures are required of you—and when—they are as follows. (The Joint Commission also has new health requirements this year – you can read up on them here.)

Keywords to know: Social drivers of health vs. social determinants of health

For a long time, social determinants of health (SDOH) has been the buzzword at the heart of how to measure health equity. But when CMS released SDOH-01 and SDOH-02, you may have noticed a slight vocabulary change: rather than social determinants of health, these two measures were labeled social drivers of health measures.

Over the last two years, there’s been a growing consensus that the term social determinants of health is counterproductive to the health equity movement. It implies that one’s health outcomes are pre-destined, that the patient has no agency over his or her health, and that healthcare policymakers and providers can’t be held accountable for these pre-ordained issues.

That’s where social drivers of health comes in. Social drivers conveys that there are variables that can be controlled and changed if we’re willing to work on them and that, ultimately, there is room for improvement. Together, we can drive healthcare and the vision of health equity forward.

Keywords to know: Health-related social needs

There is also a third term that’s picking up steam: health-related social needs (HRSN). The Joint Commission (TJC) relies exclusively on this term in its health equity requirements, and CMS uses it as an overarching label for each of the five vulnerabilities you must screen for in your SDOH measures (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety). In TJC’s R3 Report on its new requirements, it’s clear that there is a strategic intention in the word choice:

“We use the term HRSN instead of social determinants of health (SDOH) to emphasize that HRSNs are a proximate cause of poor health outcomes for individual patients as opposed to SDOH, which is a term better suited for describing populations. Understanding individual patient’s HRSNs can be critical for designing practical, patient-centered care plans. A care plan for tight control of diabetes may be unsafe for someone with food insecurity, and outpatient radiation therapy may be impractical for someone who lacks reliable transportation to treatment.”

In other words, SDOHs can be viewed as a community-wide, population-health concept, and HRSNs should be the metric by which you evaluate and treat the individual patient.

Tip #1: Ignore the noise and focus on your data

CMS has a history of initiating new measures with good intentions—but simultaneously overcomplicating the process. I wouldn’t spend too much time trying to decode all their language. Chances are the industry will have one universally accepted term in the next 3-5 years and all of this confusion will be a vestige of the past. Let CMS work out the language and focus instead on what matters: how you’re going to implement your SDOH-01 and SDOH-02 measures at your hospital.

Tip #2: Focus on just the 5 HRSNs for now (and don’t reinvent the wheel!)

Because SDOH-01 and SDOH-02 are voluntary in 2023, I suggest using this “free year” to get everything you need for 2024’s mandatory reporting in place. You don’t need to solve every health equity problem all at once. Simply focus on the five HRSNs that CMS wants you to screen for now:

1. Food insecurity
2. Housing instability
3. Transportation needs
4. Utility difficulties
5. Interpersonal safety

There is some relief in this approach because, odds are, most of this is not new territory for your hospital. You are probably already screening for some (or, if you’re really lucky, all) of these elements in your case management and/or discharge planning processes.

What is new is that CMS now expects you to capture these data points for each and every patient who walks through your doors. Talk to your case managers and social workers to see what screening processes and tools are working for them, then standardize those processes and tools hospital-wide. I also highly recommend checking out our “How to Build Your SDOH Screening Process” blog post for additional guidance.

Tip #3: Create a simple plan for patients who screen positive

If CMS’s current goal is to make sure you’re screening for HRSNs and collecting your SDOH data, don’t be surprised if the next set of requirements focuses on capturing what actions your hospital takes when a patient does screen positive for an HRSN.

Regardless of CMS’s next move, you should create a plan for how to handle positive screenings sooner rather than later. In talks with our Medisolv clients, we’ve seen that hospital staff may be resistant to implementing your SDOH screening process unless they have a clear set of tools they can give to patients that screen positive.

Once again, your case managers are probably your best ally here. They, more likely than not, have been connecting patients to community resources for years. Even something as simple as a handout with listings for food banks, transportation services, and other local resources can go a long way to making patients—and staff—feel better.

Tip #4: Don’t underestimate your Hospital Commitment to Health Equity requirement

The Hospital Commitment to Health Equity measure (HCHE) is a structural measure that is mandatory this year as part of your 2023 Inpatient Quality Reporting (IQR) requirements.

HCHE is an attestation measure—but don’t let that fool you into thinking it’s just a matter of checking off the right boxes. This measure requires you to develop, prioritize, and begin executing a health equity strategy at the executive level of your hospital.

CMS hasn’t finalized how they’re going to validate this measure, but I think it’s safe to assume they will be auditing hospitals in some capacity. If you haven’t gotten started on your HCHE measure, be sure to read our guide to the HCHE measure’s 5 domains now.

Tip #5: Mentally prepare your team for CMS’s bigger health equity vision

As I’ve already suggested, these three measures (SDOH-01, SDOH-02, and HCHE) are in no way the end game for CMS’s health equity mission. In a November 2022 blog post, CMS wrote that:

“CMS intends to move forward with our future vision for health equity data by collecting new health equity elements, aligning standards, implementing health equity scores, and providing the industry with the tools to and access to data needed to further drive health equity goals and actions.”

So, what could that mean for you and your team in the next 3, 5, or even 10 years? Here are some early predictions:

• eCQMs: It’s interesting that CMS didn’t launch its new health equity measures as eCQMs. The prevailing theory is that setting them up as they did allowed CMS, in its urgency to address health equity, to bypass the time-intensive eCQM development process and expedite the measures into regulation. Don’t be surprised if these measures evolve into eCQMs in the next few years. (Sidebar: Be sure to check out Medisolv’s new Equitable Care Module, which already treats your health equity measures like eCQMs to put you ahead of the game.)
• New requirements and programs: What is CMS going to do with all this data they’re collecting? You can bet they’re going to use it to adjust your future requirements, create new requirements for you, and implement the above-mentioned “health equity scores” that are likely to be publicly reported. It also stands to reason that they’ll use the data to identify and lobby Congress for new initiatives and programs that could impact your hospital on every level, from regulatory compliance to finance. For instance, in the 2024 IPPS Proposed Rule, CMS proposed to add health equity bonus points in the Hospital Value-Based Purchasing program similar to what they did for MSSP ACOs in the Quality Payment Program. They also indicated they are considering that same tactic for the Hospital Acquired Condition Reduction Program.
• Electronic community partnerships: In Domain #1 of the HCHE measure, one of the elements you must attest to is that your hospital has an approach for “engaging key stakeholders, such as community partners.” At this point, CMS just wants to make sure you have identified the community partners that you can refer your patients to. But CMS likely has a bigger vision: a world where hospitals can formally refer a patient who screens positive to community partners, collaborate with those partners on the patient’s case, and share the responsibility of monitoring the patient’s outcomes. Arriving at some sort of patient information exchange solution could take many years—and many technological advances—to achieve. But with all of the work happening today around dQMs, FHIR, and Universal Foundation for Quality Measures, it could be here faster than we ever imagined.

Remember that every new process feels big and hairy in the beginning. How to measure health equity will be no exception. But if you focus on the small, attainable goals we’ve outlined here, your small successes will give your hospital the momentum and morale boost it needs to tackle your next set of health equity measurement goals.

Learn More About Measuring Equity in Healthcare:

• Webinar: Equitable Care Measures Overview
• Guide: CMS’s SDOH Measures
• Guide: CMS’s Hospital Commitment to Health Equity Measure
• Guide: The Joint Commission’s Health Equity Requirements
• Brochure: The Medisolv Equitable Care Module