Five Star Support – SDOH Services that Drive HEDIS Ratings

Author: Nevin Folino

Plan providers can deliver more value to members while addressing HEDIS measures for Social Need Screening and Intervention with a scalable housing benefit that includes critical wrap-around services.

Ratings drive consumers’ decisions for everything from the appliances they purchase to the movies they buy and the healthcare plans they elect. Referencing industry standards and performance measures is especially important when selecting benefits like Medicare Advantage plans because it simplifies the vetting process. 

Specifically, we’re talking about the Healthcare Effectiveness and Data Information Set (HEDIS) that includes measures related to public health issues and, now, social determinants of health (SDOH).

HEDIS is one of the healthcare industry’s most widely used performance tools. According to the Centers for Medicare & Medicaid Services (CMS), more than 200 million people are enrolled in plans that report HEDIS results. More plans are recognizing the critical need to screen for and address SDOH factors that contribute to a person’s whole health: housing, transportation, nutrition and access to care, among other necessities that elevate quality of life. 

Housing is the core – it’s the top tier in a hierarchy of needs to stay in place as we age. 

When housing needs are addressed by a health plan that sufficiently screens members to identify SDOH gaps, HEDIS ratings go up. Star ratings go up. And consumers recognize that they are partnering with a plan provider that will protect their whole health so they can live out their years the way they choose.

HEDIS Expects More from Plans

An emphasis on HEDIS measures and Social Need Screening and Intervention (SNS-E) is driving plan providers to deliver SDOH resources to members. As a new requirement, SNS-E is included in HEDIS for Medicare Year 2023 and includes screening and intervention for: 

  • Housing 
  • Food
  • Transportation 

The effort is designed to advance health equity and to hold health plans accountable for these SDOH factors. But implementing widespread screening and offering interventions is a challenge for many plans, particularly for mid-sized and regional providers that contract with vendors for basics like transportation but are not equipped with in-house screening consultants or resources to deploy major services like stable, quality, affordable housing in neighborhoods with access to conveniences and care. 

So, how can providers deliver more to members – screen for and address SDOH factors

At Upside, we offer a solution that plan providers can offer members that addresses the most pivotal aspect of maintaining one’s whole health. Upside delivers the only fully managed living option for older adults, creating a new category for senior living. 

Housing — The Pivotal SDOH Factor 

Housing rides under the radar when it comes to delivering SDOH-related services to plan members for a few reasons. For one, housing is challenging for many plan providers to offer, unlike contracting with vendors for transportation or meals. And many providers are not aware of the life transitions members face and might not recognize that an existing housing situation simply is not working to promote long-term health. 

Housing is the core of SDOH. It is the foundation of assuring members’ whole health because without safe, quality housing that is close to care and offers amenities to age in place, other services providers deliver to members will not completely fulfill their needs. And when it comes to earning HEDIS performance points and star ratings, plan providers that can fill all of the SDOH gaps outshine the rest

The Commonwealth Fund’s Guide to Evidence for Health-Related Social Needs Interventions identified that E.R. visits were 14% to 54% lower across six studies when permanent supportive or transitional housing was provided. Hospital admission rates were 15% to 42% lower. The take-away — housing improves access to care and contributes to better total health. 

A Humana Social Determinants of Health study affirmed that 60% of our health is impacted by social factors, environmental conditions and lifestyle behaviors. When you address housing – and this will be required with new HEDIS standards – you alleviate costly E.R. visits, hospital stays, chronic conditions and even the need for prescription medications. Members stay healthier.

Screening for SDOH Gaps

With the new measure requiring plans to perform Social Need Screening and Intervention comes a challenge for many providers. Who will perform screening for food, housing and transportation? How can the process be completed in an efficient way that is comfortable for members. And most of all, how will necessary interventions be introduced after screening? 

Plan providers are in a position where they are taking on a significant responsibility to monitor for and deliver SDOH interventions. And at Upside, we understand the barriers, particularly for regional, mid-sized and local plans that perhaps do not have access to in-house or robust vendor networks. 

There’s a solution. 

Upside offers a scalable housing benefit with wrap-around support to address SDOH screening and interventions that are required by HEDIS and can help plans secure better star ratings.

Now, you can offer a housing benefit that is completely unique and flexible for your members. With our fully managed living option for older adults, members gain access to modern apartments in vibrant, safe, amenity-rich communities. Plus, they can lean on a geriatric care manager that facilitates SDOH services like transportation to appointments, meal delivery, social activities and more. Rather than enlisting in multiple vendors, you can entrust in Upside as a single-source coordinator and provider for Social Need Screening and Intervention.

The Upside Advantage 

Five Star plans are SDOH savvy and equipped with member resources to deliver necessary interventions in a way that accommodates their aging population’s lifestyle. What makes Upside different is our approach to coordinating and providing amenities that contribute to a higher-rated plan. 

  • Scalable housing in amenity-rich apartment communities
  • Comprehensive health-risk and housing assessments
  • Intelligence regarding members at low, moderate or high risk factors for chronic conditions, medication noncompliance, preventive care and other SDOH issues
  • Technology that proactively identifies care gaps
  • A geriatric care manager to coordinate SDOH services 
  • Concierge services that promote a healthy lifestyle 

Upside also offers the following supports to plans so they can deliver more value to members: 

Housing Navigation

  • Move-in support 
  • Utility setup
  • Accessibility and safety modifications 

Food Services

  • Nutrition and food access case management 
  • Evidenced-based group nutrition class 


  • Reimbursement for health-related public transportation 
  • Reimbursement for health-related private transportation 


  • Linkages to health-related legal supports 

*Upside is proud of our NPS rating of 95+

Upside can scale up or down with members’ needs.

We work with a wide range of health plans and long-term care providers with varying added-value services and benefits in place. Some plan providers are looking for a comprehensive suite of Upside living and concierge services, while others are interested in wrap-around support to enhance their existing offering.

We’re redefining what it means to age in place.

Join us on the journey and deliver the value your members are seeking as they navigate aging in place.

Upside Corporate Headquarters

6365 NW 6TH Way, Suite 200

Fort Lauderdale, FL 33309