Ten Questions to Better Understand and Serve Your Complex Care Population

Brief
Key Questions Answered
  • What are some useful questions to ask patients about their social and functional needs?
Key Themes and Takeaways

This resource shares 10 questions that California’s Medicaid managed care plans are now required to ask patients about their social and functional needs. These questions could serve as a model for other health plans and systems.

  • To better meet the needs of patients, leading health plans and accountable care organizations (ACOs) are beginning to gather person-level data about social determinants of health (i.e., access to food and housing).
  • Federal policy is fueling this trend. The 2017 CHRONIC Care Act and new CMS guidance promote assessment of functional and social needs as part of delivering more cost-effective, quality care to individuals with complex needs.
  • California recently required all Medicaid managed care programs to incorporate 10 questions into their health risk assessment that evaluate for function and social support needs. These questions were identified, reviewed, and extensively vetted through multiple stakeholder processes.
  • The questions relate to daily living, home environment, health literacy, social support, fall risk, and other categories.
Population Addressed
Adults Under 65 with Disabilities
Frail Older Adults
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
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