What Is HRSN? Health-Related Social Needs Explained

Health-related social needs (HRSN) are an individual's unmet social needs that contribute to poor health outcomes. That's the definition from the Centers for Medicare and Medicaid Services (CMS), and it's precise for a reason. HRSN is not a general concept about neighborhoods or policy. It's about this person, today, and the specific unmet need standing between them and their health.

When those needs go unaddressed, the consequences are measurable: lapses in coverage, avoidable emergency visits, worse chronic disease outcomes, and deepening health inequities, especially for historically underserved communities. That's why addressing HRSN has become a documented clinical and operational priority across Medicaid, Medicare, and value-based care programs nationwide.

HRSN vs. SDOH: an important distinction

These two terms are often used interchangeably, but they operate at different levels. Social determinants of health (SDOH) describe broad community-level conditions, such as poverty rates, neighborhood safety, and access to parks and healthy food options. HRSN describes the individual experience of those conditions.

CMS makes the distinction clearly: at the community level, these factors are referred to as social drivers of health (SDOH); the specific factors that directly impact individuals are called health-related social needs (HRSN). For example, if food insecurity affects 18% of residents in a ZIP code, that's an SDOH. Knowing that the patient in exam room 3 doesn't have enough food at home and hasn't been able to afford their insulin is an HRSN. The distinction matters because HRSN is what care teams and community organizations can actually respond to, one person at a time.

The most common HRSN categories

The domains that healthcare organizations screen for most consistently include:

• Housing instability: Difficulty paying rent, unsafe living conditions, or active homelessness. Housing is one of the strongest predictors of high emergency department utilization and poor chronic disease management.
• Food insecurity: Inconsistent access to nutritious food. It is directly linked to diabetes outcomes, mental health, and preventable readmissions.
• Transportation barriers often prevent appointments, prescription pickups, and follow-up care.
• Utility needs: Inability to pay for heat or electricity, which poses serious risks for people managing conditions such as COPD, heart failure, or diabetes.
• Social isolation has been recognized by the U.S. Surgeon General as a public health crisis, with measurable effects on cardiovascular health and cognitive decline.
• Financial strain and personal safety include difficulty affording medications and exposure to interpersonal violence, which have direct, documented effects on health outcomes.

How HRSN screening works and how it's documented

Identifying HRSN starts with a structured screening tool administered during a clinical visit or community intake. The two most widely used instruments are:

Once a need is identified, clinical documentation uses ICD-10-CM Z-codes (Z55–Z65), the standardized code range for social determinants. The Gravity Project has mapped these Z-codes to both screening tool responses and SNOMED CT codes, creating the interoperability infrastructure that allows HRSN data to flow between EHRs, payers, and community partners.

CMS finalized hospital quality reporting measures related to HRSN screening in the FY 2024 IPPS Final Rule. The measures became voluntary for CY 2024 reporting and mandatory beginning with CY 2025 reporting, although subsequent federal reporting requirements have continued to evolve. Regardless of those reporting changes, the clinical and contractual imperative to screen remains firmly embedded in CalAIM, ACO LEAD, and value-based care contracts nationwide.

Frequently asked questions

Screening is step one. The harder problem is what happens next.

Many organizations have built HRSN screening capacity. Far fewer have solved the referral gap that follows.

A positive screen for housing instability might generate a paper handout, a verbal suggestion, or a note in the chart. Without a structured workflow, nobody knows whether the person actually connected with a resource, whether the resource had capacity, or whether the need was resolved. Community-based organizations receive referrals with missing information. Follow-up falls through. The data never closes the loop.

Programs such as CalAIM and other state Medicaid initiatives, including California's Enhanced Care Management (ECM) and Community Supports, increasingly require closed-loop referral workflows. The process is straightforward:

Screen → Document (with Z-codes) → Refer → Confirm Resolution

Among hospitalized patients screened using PRAPARE, those with at least one identified HRSN had a 30-day readmission rate nearly three times higher than those without identified needs (42.5% vs. 15%). The study also found that each additional identified need was associated with roughly 2.2 times higher odds of 30-day readmission (OR 2.21, 95% CI 1.41–3.45). Screening without follow-through doesn't change those outcomes. A closed loop does.

How GridSocial closes the HRSN loop end to end

Most platforms stop at the referral. GridSocial is built for what comes after.

GridSocial is a closed-loop referral management platform purpose-built for the FQHCs, ACOs, health plans, and CBOs that carry the real weight of HRSN response. It brings all steps of the workflow together in one place, from structured screening and Z-code documentation to real-time referral routing, CBO acceptance tracking, and outcome confirmation. Hence, no community member falls through the gap between a positive screen and actual help received.

For care teams, that means visibility into whether referrals are being acted on, not just sent. For CBOs, it means receiving complete, actionable referral information instead of fragmented faxes or phone calls. For health plans and ACO leadership, it means the auditable, closed-loop documentation that CalAIM, ACO LEAD, and value-based care contracts require to demonstrate that social needs are being addressed, not just screened for.

HRSN isn't a checkbox. It's the infrastructure that makes whole-person care real. And the gap between screening and resolution is exactly where health outcomes are won or lost. GridSocial is built to close that gap, at scale, across your entire network.

The bottom line

HRSN response isn't a future capability. For organizations leading in value-based care, it's already becoming a competitive advantage.

FQHCs, ACOs, CBOs, and health plans that build the operational infrastructure to identify needs, coordinate services, and confirm outcomes will be better positioned for the next generation of value-based care.

See how GridSocial helps healthcare organizations move from HRSN screening to confirmed service delivery with end-to-end closed-loop referrals.

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References

1. Centers for Medicare & Medicaid Services. Social Drivers of Health and Health-Related Social Needs. cms.gov

2. Office of the U.S. Surgeon General. Our Epidemic of Loneliness and Isolation. hhs.gov

3. Centers for Medicare & Medicaid Services. Accountable Health Communities Health-Related Social Needs Screening Tool. cms.gov

4. Gravity Project / HL7. Resource for Documenting Social Risks Related to the AHC HRSN Screening Tool. confluence.hl7.org

5. Centers for Medicare & Medicaid Services. FY 2023 IPPS Final Rule - Screening for Social Drivers of Health Measures. cms.gov

6. Kliewer D, McGillen B. Inpatient Screening for Social Determinants of Health: A Quality Improvement Initiative. PubMed Central. 2024. ncbi.nlm.nih.gov/pmc/articles/PMC11626580