CMS Health Equity Toolkit


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DISCLAIMER

The New Jersey Hospital Association (NJHA) has organized this toolkit using federal, state and stakeholder sources, with up-to-date standards and recommendations at the time of publication. It has been developed by NJHA for the sole use of NJHA and its members, to assist with the provision of equitable care and compliance with the new CMS health equity requirements. NJHA does not intend to provide this information to be utilized as legal, regulatory or compliance advice, and all information should be considered in consultation with legal counsel, regulatory and compliance officers.

OBJECTIVES

This NJHA toolkit, Meeting the Centers for Medicare and Medicaid Services’ Reporting Requirements for Health Equity, provides an overview of the CMS Framework for Health Equity 2022-2023 and delivers resources to support health systems and hospitals in advancing health equity in their own organizations and communities.

The objectives of this toolkit are to

  1. Assist health systems and hospitals in achieving compliance with CMS’ reporting requirements for the Health Equity Structural Measures (a) hospital commitment to health equity; and (b) social drivers of health.
  2. Provide resources to support health systems and hospitals in making equity a priority in care delivery.
  3. Highlight practices nationally where partnerships with communities are driving successful change.

QUICK LINKS

Use these links to navigate through the resource:

Introduction
Hospital Commitment to Health Equity Structural Measures
Measure One: The Hospital Commitment to Health Equity
Domain 1 | Domain 2 | Domain 3 | Domain 4 | Domain 5
Measure One Resources
Measure Two: Social Drivers of Health
Measure Two Resources

INTRODUCTION

In Framework for Health Equity 2022-2023, CMS defines health equity as "the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes."

CMS presents a review of foundational elements needed to incorporate health equity efforts across all programs. The five priorities identified in the Framework are essential for attaining health equity across all programs and communities. They include:

  1. Expand the collection, reporting, and analysis of standardized data.
  2. Assess causes of disparities within CMS programs, and address inequities in policies and operations to close gaps.
  3. Build capacity of health care organizations and the workforce to reduce health and health care disparities.
  4. Advance language access, health literacy, and the provision of culturally tailored services.
  5. Increase all forms of accessibility to health care services and coverage.

Note: The initial launch of this toolkit is focused on the first priority – expand the collection, reporting and analysis of standardized data. Further sections will continue to expand the discussion on the CMS requirements as it relates to social determinants of health data collection, crosswalks and select resources.

HOSPITAL COMMITMENT TO HEALTH EQUITY STRUCTURAL MEASURES

Hospitals participating in the Hospital Inpatient Quality Reporting Program (IQR) must attest to meeting the requirements of the structural measures annually.

NOTE:

  • The Hospital Commitment to Health Equity structural measure was adopted into the Hospital IQR Program beginning with calendar year (CY) 2023 reporting period/fiscal year (FY) 2025 payment determination and for subsequent years.
  • The Social Drivers of Health structural measures will be voluntary beginning with the CY 2023 reporting period and mandatory beginning with the CY 2024 reporting period/FY 2026 payment determination and for subsequent years.

MEASURE ONE: THE HOSPITAL COMMITMENT TO HEALTH EQUITY

Hospital Commitment to Health Equity is an attestation-based structural measure that acknowledges a hospital’s commitment to health equity using a suite of equity-focused organizational competencies aimed at achieving health equity for racial and ethnic minority groups; people with disabilities’ members of the lesbian, gay, bisexual, transgender and queer (LGBTQ+) community; individuals with limited English proficiency; rural populations; religious minorities; and people facing socioeconomic challenges.

The measure consists of five domains, and a hospital must evaluate and determine whether it can affirmatively attest to each domain and any multiple sub-elements.

Domain 1: Equity is a Strategic Priority

Hospital commitment to reducing healthcare disparities is strengthened when equity is a key organizational priority.

  1. Our hospital strategic plan identifies priority populations who currently experience health disparities.
    Examples of “priority populations” include but are not limited to:
    • Persons belonging to minority racial or ethnic groups
    • Persons living with a disability
    • Being a member of the lesbian, gay, bisexual, transgender and queer (LGBTQ+) community
    • Being near or below the poverty level
    • Populations impacted by drivers of health, such as social determinants (e.g., language proficiency, housing or food insecurity, low literacy, difficulty with access to transportation or other factors unique to a hospital’s patient community)
    • Any other populations that have been underserved and/or historically marginalized by the healthcare system.
  2. Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieving these goals.
  3. Our hospital plan outlines specific resources which have been dedicated to achieving our goals.
    • Examples of specific resources include but are not limited to dedicated staffing, structural resources, funding, and trainings.
  4. Our hospital strategic plan describes our approach for engaging key stakeholders, such as community-based organizations.

All the four items above must be included in the plan for a hospital to receive a point in the numerator in measure of attainment.

Domain 2: Data Collection

The collection of valid and reliable demographic and social determinant of health data on patients served in a hospital is a major step in identifying and eliminating health disparities.

The hospital attests that it engages in the following activities:

  1. Our hospital collects demographic information (such as self-reported race, national origin, primary language, and ethnicity data) and/or social determinant of health information on most of our patients, which include, but are not limited to the following:
    • Self-reported race and ethnicity
    • Socioeconomic status
    • Being a member of the LGBTQ+ community
    • Being a member of a religious minority
    • Living with a disability
    • Living in a rural area
    • Language proficiency
    • Health literacy
    • Access to primary care/usual source of care
    • Housing status or food security
    • Access to transportation.
  2. Our hospital has training for staff in culturally sensitive collection of demographics and/or social determinant of health information.
  3. Our hospital inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using certified EHR technology.

All three items in Domain 2 must be included in the plan for a hospital to receive points in for the domain in the measure's numerator.

Domain 3: Data Analysis

Effective data analysis can provide insights into which factors contribute to health disparities and how to respond.

  1. Our hospital stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information on hospital performance dashboards.

The purpose of measuring stratification is to understand if certain patient groups are receiving better care. Stratification in this case refers to examining quality measure results by subgroups of patients to identify important gaps in quality between patient groups.

Hospitals may develop stratification metrics for priority populations (as defined by its organization e.g., by race and ethnicity, economic burden, etc.) and monitor results on these metrics using existing internal quality dashboards.

Domain 4: Quality Improvement

Health disparities are evidence that high quality care has not been delivered equitably to all patients. Engagement in quality improvement activities can improve quality of care for all patients.

  1. Our hospital participates in local, regional or national quality improvement activities focused on reducing health disparities.

Quality improvement (QI) activities may include participation in collaboratives, partnerships and coalitions focused on decreasing health disparities, including among specific patient populations or for specific medical conditions – e.g., working with Medicare Quality Improvement Networks, or joining collaboratives such as The Health Equity Collaborative; Eastern U.S. Quality Improvement Collaborative; The Alliance for Innovation on Maternal Health (AIM) or Perinatal Quality Collaboratives (PQCs) (such as the New Jersey Perinatal Quality Collaborative); American Hospital Association Center for Health Innovations’ Hospital Community Collaborative; Million Hearts; or other local, regional, and national initiatives as long as the effort has a specific focus on improving quality and reducing disparities.

Domain 5: Leadership Engagement

Leaders and staff can improve their capacity to address disparities by demonstrating routine and thorough attention to equity and setting an organizational culture of equity.

  1. Our hospital senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity. CMS defines “hospital senior leadership” as the C-suite and board of trustees, and not just quality committees or subcommittees of the board, as well as the chief medical officer and senior leaders among hospital medical staff.
  2. Our hospital senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors.

The two items in Domain 5 must be included in the plan for the hospital to receive one point for the domain in the numerator of the measure.

MEASURE ONE RESOURCES

Centers for Medicare & Medicaid Services

Web-Based Data Collection
Hospital Inpatient Quality Reporting (IQR) Program Measures (cms.gov)
Participating hospitals are required to complete web-based measure data collection. This is done through an online data collection form within the Hospital Quality Reporting Portal. This resource provides details on web-based data collection and attestation guidance

Strategic Plan, Health Equity
CMS Strategic Plan Health Equity Fact Sheet
The first pillar of the Strategic Plan is health equity. CMS’ strategy to advance health equity addresses the health disparities that underlie our health system through stakeholder engagement and by building this pillar into the core functions of CMS.

American Hospital Association

A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health
A-playbook-for-fostering-hospitalcommunity-partnerships.pdf (aha.org)
This American Hospital Association playbook provides a framework for cultivating effective partnerships between hospitals and community organizations. The resource contains tools, including worksheets to use together to develop strategies together to achieve common goals; sample agendas are included for structures and ideas for kick-off meetings and next steps; and ideas and details are discussed regarding the formative stages of assembling partnerships and ideas for sustainability, such as celebrating success along the way. The compendium of case studies provides insights into building capacity in partnerships by highlighting examples of hospital community partnerships.

Achieving Health Equity: A Guide for Health Care Organizations
Improving Health Equity: Guidance for Health Care Organizations | IHI - Institute for Healthcare Improvement
This white paper provides guidance on how health care organizations can reduce health disparities related to racial or ethnic groups; religion; socioeconomic status; gender; age; mental health; cognitive, sensory or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Health Equity, Diversity & Inclusion Measures for Hospitals and Health System Dashboards
ifdhe_inclusion_dashboard.pdf (aha.org)
The American Hospital Association’s Institute for Diversity and Health Equity provides this resource to support the work of interdisciplinary team(s) reporting to the C-suite executives.

The Dashboard’s domains include:

  • Data collection, stratification and use
  • Cultural competency training
  • Diversity and inclusion in leadership and governance
  • Strengthen community partnerships

Each domain includes measure descriptions and examples of operationalizing each, and supporting tools and resources featuring briefs, guides and toolkits to help hospitals and health systems make progress toward achieving that measure.

Societal Factors that Influence Health
Societal Factors That Influence Health | AHA
This framework is intended to aid hospitals in addressing the specific social needs of their patients and communities and the systemic causes of health inequities. The resource includes podcasts, webinars and recent case studies from hospitals and health systems that address different topics on the social determinants of health.

Advancing Health Equity Through Organizational Change
https://journals.lww.com/hcmrjournal/Fulltext/2022/07000/Advancing_health_equity_through_organizational.11.aspx
In this environmental scan to identify central principles for implementing change in health systems, systematic organizational changes/common themes were identified to promote health equity by conducting interviews with 19 experts in health equity and hospital executives. Consistent with the literature on organizational change, interviewees described a variety of systematic approaches to change, all of which involve the following core components: (a) committed and engaged leadership; (b) integrated organizational structure; (c) commitment to quality improvement and patient safety; (d) ongoing training and education; (e) effective data collection and analytics; and (f) stakeholder communication, engagement and collaboration. This review will provide leaders with a variety of approaches to consider for application based upon the unique internal and external drivers to advance equity at their health systems.

Data Collection on Priority Populations and SDOH
Research on Integrating Social & Medical Care | SIREN (ucsf.edu)
This study's objective was to assess caregiver preferences for social needs screening in the inpatient pediatric setting. Caregivers were surveyed about the importance of screening, their comfort with it and which domains were felt to be acceptable for screening. Many caregivers reported the acceptance of and comfort with social needs screening in the inpatient setting. The details of the findings inform future hospital-wide social needs screening efforts.

Health Equity Gap Analysis/Checklist
Health Equity Gap Analysis (qualityimprovementcollaborative.org)
The Eastern Quality Improvement Collaborative provides a checklist for organizations to assess how effectively health equity best practices are being incorporated into organizational operations.
Recommendations and practice examples in this resource address various issues including language, culture, health literacy, other communication barriers, mobility needs and the concerns of lesbian, gay, bisexual and transgender (LGBT) patients. As many of these issues can arise at various points along the care continuum, several recommendations are used to reinforce the importance of incorporating these practices into care delivery.

MEASURE TWO: SOCIAL DRIVERS OF HEALTH

Performance Measure Name: Screen Positive Rate for Social Drivers of Health

Description: The Screen Positive Rate for Social Drivers of Health Measure provides information on the percent of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, were screened for a Health-Related Social Need (HRSN) and who screen positive for one or more of the following five HRSNs: food insecurity, housing instability, transportation problems, utility difficulties or interpersonal safety.

Measure Numerator: The numerator consists of the number of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, who were screened for all five HSRN and who screen positive for having a need in one or more of the following five HRSNs (calculated separately): Food insecurity, housing instability, transportation needs, utility difficulties or interpersonal safety.

Measure Denominator: The denominator consists of the number of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all the following five HSRN (food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety) during their hospital inpatient stay.

Exclusions: The following patients would be excluded from the denominator: 1) Patients who opt out of screening; and 2) patients who are themselves unable to complete the screening during their inpatient stay and have no caregiver able to do so on their behalf during the inpatient stay.

Clarifying Information: The result of this measure would be calculated as five separate rates. Each rate is derived from the number of patients admitted for an inpatient hospital stay and who are 18 years or older on the date of admission, screened for an HRSN and who screen positive for each of the five HRSNs—food insecurity, housing instability, transportation needs, utility difficulties or interpersonal safety—divided by the total number of patients 18 years or older on the date of admission screened for all five HRSNs.

MEASURE TWO RESOURCES

Centers for Medicare & Medicaid Services

The Accountable Healthy Communities Health-Related Social Needs Screening Tool
The AHC Health-Related Social Needs Screening Tool (cms.gov)
The tool can help providers find out patients’ needs in these five core domains that community services can help with:

  • Housing instability
  • Food insecurity
  • Transportation problems
  • Utility help needs
  • Interpersonal safety

Center for Medicare and Medicaid Innovation (CMMI) Accountable Health Communities Model
https://innovation.cms.gov/innovation-models/ahcm
Resources, tools and case studies for implementing SDOH screening.

Inventory of Resources for Standardized Demographic and Language Data Collection
Inventory of Resources for Standardized Demographic and Language Data Collection (cms.gov)
Collecting standardized patient demographic and language data across healthcare systems is an important first step toward improving population health. Comprehensive patient data on race, ethnicity, language and disability status are key to identifying disparities in quality of care and targeting quality improvement interventions to achieve equity.

This resource is a robust source of a variety of guidance documents that includes:

  • Minimum standards for data collection as outlined by the U.S. Department of Health and Human Services
  • Best practices and guidelines for healthcare organizations in implementing standardized data collection, including information to address key challenges in collecting these data
  • Training tools and webinars to help healthcare organizations educate their staff on the importance of standardized data collection and best practices for data collection
  • Articles, books and videos that provide in-depth discussion of issues, challenges, recommendations and best practices in standardized data collection.

American Hospital Association

Screening for Social Needs: Guiding Teams to Engage Patients
screening-for-social-needs-tool-value-initiative-rev-9-26-2019.pdf (aha.org)
This American Hospital Association tool helps guide hospital leaders as they navigate the best way to engage their patients in screening conversationsThis guide’s intent is to offer ideas about those screening conversations and direct readers to AHA’s other tools and resources aimed at addressing the social determinants in our communities.

The Six Levers of Transformation
The Six Levers of Transformation | Equity (aha.org)
The journey toward creating equitable and inclusive organizations will require assessing embedded practices and policies; engaging in internal and external system changes; and acknowledging structural barriers that compromise equity. Research and experience show that leading health equity strategies cut across these six major areas within healthcare organizational structures. Explore these six levers of transformation to understand capabilities to improve performance, what actions you may take and how to move forward on the journey.

  • Culturally appropriate patient care
  • Equitable and inclusive organizational policies
  • Collection and use of data to drive action
  • Diverse representation in leadership and governance
  • Community collaboration for solutions
  • Systemic and shared accountability

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Implementation and Action Toolkit
Opportunities to Leverage Social Determinants of Health Data for Action (prapare.org)
The PRAPARE Implementation and Action Toolkit is designed to provide interested users with the resources, best practices and lessons learned to guide implementation, data collection and responses to social determinant needs. This Toolkit is based on the experiences, best practices and lessons learned of our early adopting and pioneering community health centers. We thank them for sharing their innovations and lessons learned so that others can advance their own social determinants of health journey.

Social Determinants of Health Screening and Management: Lessons at a Large, Urban Academic Health System
Social Determinants of Health Screening and Management: Lessons at a Large, Urban Academic Health System (sciencedirectassets.com)
In October 2022, a multisite social determinants of health screening initiative expanded across seven emergency departments of a large, urban hospital system. The initiative's aim was to identify and address those underlying social needs that frequently interfere with a patient's health and well-being, often resulting in increased preventable system utilization. Building on an established Patient Navigator Program, an existing screening process and longstanding community-based partnerships, an interdisciplinary workgroup was formed to develop and implement the initiative. Technical and operational workflows were developed and implemented, and new staff members were hired and trained to screen and support patients with identified social needs. In addition, a community-based organization network was formed to explore and test social service referral strategies.

Social Needs Screening Tool Comparison Table
https://sirenetwork.ucsf.edu/tools-resources/resources/screening-tools-comparison
University of San Francisco California compilation of screening tools to aid in comparing tool characteristics.