SDOH Items on the MDS: Be Proactive to Avoid Staff—and Resident—Negativity

The new social determinants of health (SDOH) items that are being added to the MDS effective Oct. 1, 2023, can be shocking to nurse assessment coordinators (NACs) and other members of the interdisciplinary team in nursing homes, says Nelia Sakai Adaci, RNC, BSN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CDONA, IPCO, chief operating officer of The CHARTS Group in Lakewood, NJ.


Nelia Sakai Adaci, RNC, BSN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CDONA, IPCO, chief operating officer of The CHARTS Group

In total, there are seven new or revised SDOH items, including subitems:

A1005 (Ethnicity)
A1010 (Race)
A1110 (Language)

  • A1110A (What Is Your Preferred Language?)
  • A1110B (Do You Need or Want an Interpreter to Communicate With a Doctor or Healthcare Staff?)
A1250 (Transportation (From NACHC))
B1300 (Health Literacy)
D0700 (Social Isolation)

“The reason behind the widespread shock surrounding these items is that the political climate in the United States is highly charged, and having MDS questions targeting ethnicity (A1005) and race (A1010) in particular may seem intrusive and political,” says Adaci. “A lot of people feel quite strongly about it. The default attitude of many NACs and others I have spoken with, including some administrators and directors of nursing (DNSs), is to question, ‘Why are these items even on the MDS?’”

Carol Maher

Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC, director of education for Hansen, Hunter & Co. PC

That same question may also be asked by some residents, stresses Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA. “Even now, residents often don’t want to discuss what they consider to be extremely personal—and nonmedical—information.”

So, some residents may respond to SDOH questions with “Why do you want to know that? I’m not going to tell you,” explains Maher. “Families are sometimes cautious about providing personal information as well because they are unsure how it will be used.”

That general nervousness about providing personal information means that the interviewer will need to present the SDOH questions carefully, suggests Maher. “The steps for assessment for the ethnicity and race items in the draft v1.18.11 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (pages A-17 and A-20, respectively) include examples of how to introduce the questions to put concerned residents at ease,” says Maher. “However, the interviewer’s attitude will be critical. If you present these questions as a positive way for your team to learn about the resident to provide culturally competent care for the resident, you are more likely to get answers than if you act like the government is trying to find out this information for potentially unfortunate reasons.”

Why Residents Need to Be Willing to Talk

“The coding instructions for race, ethnicity, and transportation (items A1005, A1010, and A1250) in the draft RAI User’s Manual tell assessors to assess these items via a resident interview,” says Maher. “Interestingly, if the resident declines to answer, you are not allowed to ask anyone else, such as a family member or the legally authorized representative, and you are not allowed to use the medical record, such as documentation from the hospital, to determine the answers. Your only option if the resident declines to answer is to code these items as Y (Resident Declines to Respond).”

If the resident is unable to answer, assessors must code X (Resident Unable to Respond) for A1005, A1010, and A1250, explains Maher. “However, you also are allowed to ask the family, significant other, or legally authorized representative to obtain the answers, which you may code in addition to the X code. If the resident has no family, significant other, or legally authorized representative, you then may use the medical record to determine those answers and code them in addition to the X code. So, it’s a ‘check all boxes that apply’ scenario, including the X code.”

Note: The coding instructions for A1110 (Language) don’t have these restrictions, but the steps for assessment (page A-23 of the draft RAI User’s Manual) do outline a distinct order for the information sources to be used, starting with the resident; then, a family member, significant other, or guardian/legally authorized representative; and, as a last resort, documentation in the medical record.

The coding instructions for B1300 and D0700 go a step further than A1005, A1010, and A1250, not allowing assessors to use any information source except the resident in any circumstances, adds Maher. “You simply code 7 if the resident declines to respond or 8 if the resident is unable to respond.”

The following excerpt from the steps for assessment for both items (pages B-15 and D-18 of the draft RAI User’s Manual) explains the data source limitation:

This item is intended to be a resident self-report item. No other source should be used to identify the response.

“The Centers for Medicare & Medicaid Services (CMS) making this distinction that assessors may only obtain certain assessment information directly from the resident is a first for the MDS,” notes Maher. “No current MDS items restrict you to a sole data source—in this case the resident—for assessment information. For example, the coding instructions for the Brief Interview for Mental Status (BIMS) (page C-17 of the draft manual) tell you to conduct the Staff Assessment for Mental Status if the resident chooses not to answer four or more of the items in C0200 – C0400.”

Why Complete and Accurate SDOH Data is a Must 

Nursing home leaders need to pay attention to the SDOH MDS items for the following reasons:

* SDOH data will be monitored. The federal government and other entities will use the SDOH items to address health equity both within nursing homes and across post-acute care settings, says Adaci. “The other post-acute care settings, including home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs) will be collecting the same standardized data.” 

* Culturally competent care planning and discharge planning are at stake. While the SDOH data will be used globally to help healthcare providers reduce heath disparities, it can also have a direct, immediate impact on the individual resident’s care plan, notes Maher. “To have a culturally competent comprehensive care plan as required under F-tag 656 (Develop/Implement Comprehensive Care Plan), you need to understand what each resident’s culture is. Knowing the resident’s ethnicity, for example, can be important in meeting the resident’s food preferences or knowing which holidays they celebrate and what those celebrations usually include.”

The SDOH items are also critical to strong discharge planning, says Adaci. “For example, the team may need to adjust the discharge plan and put the resident in touch with community resources if they have transportation barriers (A1250) that could prevent them from going to a follow-up appointment with their primary care physician or getting prescriptions filled.”

* SDOH items impact the Skilled Nursing Facility Quality Reporting Program (SNF QRP). All seven SDOH items are required on the 5-Day PPS assessment, and three of them are also required on the Part A PPS Discharge assessment to count toward each SNF’s annual MDS data completion threshold beginning with fourth-quarter 2023 (Oct. 1 – Dec. 31, 2023) submissions for the fiscal year (FY) 2025 SNF QRP program year. However, some of the items cannot be dashed, reducing the likelihood of inadvertent dashing. Dashing in these items will generate a fatal error on the Final Validation Report, preventing the MDS assessment from being accepted into the iQIES database, according to the v3.01.1 MDS data specifications.

The following chart adapted from the SNF QRP Overview of Data Elements Used for Reporting Assessment-Based Quality Measures and Standardized Patient Assessment Data Elements Affecting FY 2025 APU Determination explains the SNF QRP data completion threshold requirements effective this Oct. 1:

MDS Section & NumberData Element Label/DescriptionPPS 5-Day A0310B=[01]Part A PPS Discharge A0310H=[1]Q4 2023 MDS 3.0 Version 1.18.11
A1110ALanguage: What is your preferred language?XX
A1110B*^Language: Need or want an interpreter to communicate with a doctor or health care staff?XX
B1300*^Health LiteracyXXX
D0700*^Social IsolationXXX


* Dash (–) is not an allowable response value for this item.

^ The data elements table does not exactly match the information in the v3.01.1 MDS data specifications for these items. According to the data specs, a dash is an allowable response for these items in some circumstances, and if A0310B=[01] or A0310H=[1], a payment reduction warning message will be generated on the Final Validation Report when these items are dashed.

* Some states plan to use SDOH data for Medicaid payment. While the SDOH items may impact fee-for-service Medicare Part A payment via the SNF QRP if the items aren’t completed as required, they could impact Medicaid payment in some states as well, says Maher. “For example, California plans to incorporate the completion of the racial and ethnicity items into the state’s supplemental payment system. That could be an issue if the resident declines to answer, depending on how the system ultimately is set up, because you can’t access other sources of information to get the answers.” 

How to Get the Interdisciplinary Team on Board

To help the interdisciplinary team put aside difficult feelings, it’s important to focus on the intent of the SDOH items, says Adaci. “You need to defuse the situation—and take away the team’s preconceived notions—by making sure they know that these questions aren’t political or racial profiling. If you don’t take away that focus, staff won’t listen, and you may end up having negative interviews with residents and potentially inaccurate coding, as well as not having this information fully incorporated into care planning and discharge planning.”

One way to re-frame the conversation is to focus on the overarching goal of value-based outcomes, suggests Adaci. “CMS wants to protect the Medicare Trust Fund by ensuring that there are successful transitions of care within the care continuum to prevent rehospitalizations. From that perspective, the SDOH items and the need for health equity make sense. The clinical literature includes a significant amount of data showing that addressing the SDOH improves care transitions.”

Most people react a lot more calmly when they understand that this is an issue that the entire post-acute care sector must address, adds Adaci. “The SDOH items will give all post-acute providers the data to be able to care for each resident using more person-centered, individualized care planning that improves outcomes and reduces rehospitalizations.”

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