Implementation of a Social Health Assessment in a Mental Health Outpatient Practice: A Quality Improvement Project
Abstract
One-third of Americans are grappling with stress linked to meeting their basic human needs, such as stable housing, adequate food, and reliable transportation. Social determinants of health (SDOH) impact an individual’s health outcomes and health status. The Centers for Medicaid and Medicare (CMS) recognize the importance of screening for SDOH and, as of 2024, have implemented billing processes whereby social health assessments are reimbursable. The aim of this quality improvement project was to implement social health assessments in an outpatient mental health private practice. The framework of a plan do study act (PDSA) approach was utilized to initiate and improve the designated clinical setting regarding SDOH assessment. PDSA cycles were completed once every 7 days for four cycles within the 28 days of the quality improvement project. The primary aim of this quality improvement project was to increase assessment rates for SDH assessment from 0% to 50% utilizing a modified version of the health leads screening tool in a small mental health outpatient practice in Rhode Island. The period for the quality improvement project was 12 weeks. Office staff, ancillary staff, medical doctors, nurse practitioners, and therapists were all trained in utilizing the modified health leads assessment tool. The quality improvement project was designed to aid in the referral to community resources for identified social needs. In a 12-week period, 2,539 patients were assessed, and 1,871 patients affirmed an SDOH need and requested referrals. Completion of the assessments netted the practice $5,213.27 utilizing new reimbursement rate provided by CMS, even considering a 70% rejection rate on G- 0136 code claims for the social health assessments. Over 4 weeks, a net total of $1,513.27 of realized income resulted from the quality improvement project. Assessing SDOH resulted in identified SDOH needs and facilitated referrals to patients to aid with social needs.
Disciplines
Nursing | Social Work
Subject Area
Nursing; Social research; Social work; Mental health
Recommended Citation
Arden, Meredith, "Implementation of a Social Health Assessment in a Mental Health Outpatient Practice: A Quality Improvement Project" (2025). Doctoral Dissertations. 229.
https://digitalcommons.salve.edu/doctoral_dissertations/229
Department
Nursing (NUR)
First Advisor
Stager, Sharon
Second Advisor
Lynch, Shelley
Date of Award
2025
Document Type
Dissertation
Degree Name
D.N.P.