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Social Determinants of Health

Provide a uniform means to collect information through City-funded social service contracts on the unmet needs encountered by service customers. Data otherwise not available will be used to inform the City and public on unmet needs that need attention and aggregate progress of city-funded services.

The Division of Behavioral Health and Wellness has incorporated the administration of a Social Determinants of Health screening tool into many of the FY20 contracts using the following language:

a)       The Contractor will administer the FCS Social Determinants of Health Screening Tool when a client/participant engages and exits funded services, or annually depending on length of stay in services. 

i.         The Contractor will track results on an FCS-provided spreadsheet.

ii.       Quarterly reports will include aggregate results from the screening tool, a narrative highlighting connections to supportive resources, identification of barriers to serve comprehensive needs of clients, and suggested solutions to address barriers to obtaining services.

The purpose is to provide a uniform means to collect information through City-funded social service contracts on the unmet needs encountered by our clients.  Data that is collected and reported to the City will be used to inform the City on unmet needs that may require attention and/or funding by the City, and will provide the aggregate progress of many of the Department’s funded services. The Department modified questions from Accountable Health Communities Health Related Social Needs Screening Tool issued by the Centers for Medicare and Medicaid Services (CMS) in crafting this tool.  Multiple Albuquerque agencies and health providers use the original CMS screening tool, which allows data collected by the City can be compared with a rich local and national data set.   Information that is reported by our Partner agencies will be reported on this page.