AHC HRSN Screening Tool

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Introduction

This health care provider participates in the Accountable Health Communities (AHC) program funded by the Centers for Medicare and Medicaid Services. This program can help connect you to services in your community that may improve your health. Many of these services are low cost or free of charge. By answering these questions we may be able to provide you with connections to services or programs that may help you.

Your information will be kept confidential. The information that you provide will not impact your Medicare or Medicaid eligibility status.

You should answer the questions in your own way. There are no right or wrong answers.

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Client Information
for CMS Beneficiary
      View open screenings

      Open Screenings

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      Information

      1.Complete the following statement. I am answering this survey about
      Other:

      For the rest of the survey, please think about the person you selected in Question 1 when answering the questions. Please select the option that best describes him or her.

      2.How many times have you received care in an emergency room (ER) over the last 12 months?If you are in the ER now, please count your current visit. Please do not count urgent care visits.

      3.Do you live in any of the following locations?

      Before you continue, please make sure you have selected responses to the above questions and completed this section.



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      Please think about the person you selected in Question 1 (either yourself or another) when answering the questions. Please select the option that best describes him or her.

      Living Situation

      4.What is your living situation today?

      5.Think about the place you live. Do you have problems with any of the following?CHOOSE ALL THAT APPLY


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      Food

      Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.

      6.Within the past 12 months, you worried that your food would run out before you got money to buy more.

      7.Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.

      Transportation

      8.In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting to things needed for daily living?

      Utilities

      9.In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?



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      Safety

      Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.

      10.How often does anyone, including family and friends, physically hurt you?

      11.How often does anyone, including family and friends, insult or talk down to you?

      12.How often does anyone, including family and friends, threaten you with harm?

      13.How often does anyone, including family and friends, scream or curse at you?


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      Please think about the person you selected in Question 1 (either yourself or another) when answering the questions. Please select the option that best describes him or her.

      Financial Strain

      14.How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:

      Employment

      15.Do you want help finding or keeping work or a job?

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      Background

      Please think about the person you selected in the first question (either yourself or another) when answering the following. If you are answering for someone else, please select the option that best describes him or her.

      16.What is your sex?

      17.Are you Hispanic, Latino/a, or of Spanish origin?CHOOSE ALL THAT APPLY

      18.Which one or more of the following would you say is your race?CHOOSE ALL THAT APPLY
      Other:

      19.What is the highest grade or year of school you completed?If you are answering this survey for a child under the age of 18, please answer this question about his/her parent or legal guardian.

      20.How many people do you currently live with?Please count yourself,your spouse or partner, your children, and any other dependents. If you live alone, put 1.

      21.What is your annual household income from all sources?Please include your income as well as the income for everyone you counted above in your household.


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      THANK YOU!

      Thank you very much for answering these questions.