NQF Issues Guidance for Medicaid Programs to Improve Health by Addressing Social Needs 

JAN 25, 2018

CONTACT: Sofia Kosmetatos

NQF Issues Guidance for Medicaid Programs to Improve Health by Addressing Social Needs

Washington, DC
—A new report from the National Quality Forum (NQF) outlines a systematic approach for Medicaid programs to better support efforts to collect and use data about individuals’ social needs and increase collaboration between communities and healthcare providers to improve beneficiaries’ health.

“We know that what really affects health and health outcomes is where and how people live and work,” said Shantanu Agrawal, MD, MPhil. “This project, which is part of NQF's Health Equity initiative to reduce health disparities, offers Medicaid programs a strategic blueprint to address social needs that affect peoples’ health.”

In collaboration with the Centers for Medicare & Medicaid Services, NQF convened an Expert Panel representing a variety of stakeholder groups—including clinicians, researchers, health plans, health systems, and consumer advocates—to provide strategic guidance to Medicaid programs about collecting and using data about social needs that impact health. The report identifies Medicaid programs as the primary healthcare entities (“the hub”) connecting healthcare to non-health services that can address social needs (the “spokes”), such as housing and food support, employment services, and home and community-based services. The panel focused on food insecurity and housing instability as key areas for which Medicaid programs can support data collection efforts in the short term, given the growing body of evidence linking food insecurity and housing instability to a negative impact on health outcomes.

The Expert Panel suggests that state Medicaid programs support collection of data about social needs that impact health by strengthening linkages between communities and healthcare systems, facilitating the exchange of information, leveraging payment models, and incentivizing the discovery of new ways to deliver care. With input from the public, NQF members, and key informants (i.e., individuals in leadership roles in organizations working to mitigate the incidence and impact of food insecurity and housing instability), the panel specifically recommends that Medicaid programs:

  • Acknowledge that Medicaid has a role in addressing social needs that impact health
  • Create a comprehensive, accessible, routinely updated list of local community resources for healthcare organizations
  • Harmonize tools that assess social needs that impact health to ensure that they collect and document the same type of information
  • Create standards for inputting and extracting social needs data from electronic health records to strengthen information sharing between health and non-health providers and programs
  • Increase information sharing between government agencies
  • Expand the use of waivers and demonstration projects to begin to learn what works best for screening and addressing social needs that impact health.

“This report shares important, practical guidance for healthcare and community stakeholders to work together toward a more holistic approach to improving the health of our nation’s most vulnerable populations,” said Romana Hasnain-Wynia, PhD, MS, chief research officer, Denver Health, and chair of the NQF Expert Panel.


The National Quality Forum leads national collaboration to improve health and healthcare quality through measurement. Learn more at www.qualityforum.org.