CMS-10409 Social Determinants of Health

Social Determinants of Health Mockups

R0320. Food

Enter Code

A. Within the past 12 months, you worried that your food would run out before you got money to buy more. 0. Often true 1. Sometimes true 2. Never true 7. Patient declines to respond 8. Patient unable to respond B. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. 0. Often true 1. Sometimes true 2. Never true 7. Patient declines to respond 8. Patient unable to respond

Complete list of HRSN items (Living Situation, 2 Food items, Utilities, Revised Transportation item)

Section R

Health-Related Social Needs

R0310. Living Situation
Enter Code	What is your living situation today? 0. I have a steady place to live 1. I have a place to live today, but I am worried about losing it in the future 2. I do not have a steady place to live 7. Patient declines to respond 8. Patient unable to respond

R0330. Utilities
Enter Code	In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home? 0. Yes 1. No 2. Already shut off 7. Patient declines to respond 8. Patient unable to respond

R0340. Transportation
Enter Code	In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? 0. Yes 1. No 7. Patient declines to respond 8. Patient unable to respond