On Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS version 1.20.1 item sets and item matrix for implementation on Oct. 1, 2025. The change history included with the item sets indicates planned changes to sections A (Identification Information), B (Hearing, Speech, and Vision), I (Active Diagnoses), and O (Special Treatments, Programs, and Procedures). These pending revisions include the removal of item O0400 (Therapies), which will be replaced by the less-detailed O0390 (Therapy Services).
“However, the biggest change that the nurse assessment coordinator (NAC) and the rest of the interdisciplinary team (IDT) will face in October 2025 is the addition of the new section R (Health-Related Social Needs),” says Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RAC-MTA, president and CEO of Celtic Consulting in Torrington, CT. Note: See a chart excerpted from the change history detailing the proposed section R at the end of this article.
While even draft coding instructions remain months away, the NAC can take the following steps to begin laying the groundwork for the smooth implementation of section R:
Understand—and educate the team—on the why behind section R
There will be 11 social determinants of health (SDOH) items on the MDS effective Oct. 1, 2025, notes McCarthy. “The draft section R includes five of these SDOH items: four new ones addressing living situation, food, and utilities and one modified transportation item originally from section A. But, I potentially could see CMS moving additional SDOH items, such as B1300 (Health Literacy) or D0700 (Social Isolation), into section R at some point.”
CMS is adding section R to help ensure that healthcare, including post-acute care, is fair and equitable in the United States, says McCarthy. “It’s hard to understand who inequities impact the most and how to deal with those inequities without adequate data. Section R will help the IDT ask the right questions to gather the data to reduce inequities. So, it makes sense that CMS is moving in this direction.”
In many ways, the SDOH items aren’t that different from the resident interview items in section F (Preferences for Customary Routine and Activities), which have been around for a very long time, adds McCarthy. “Section F gives you information about how the resident prefers to be cared for that you can incorporate into care plans, starting with the baseline care plan. Similarly, the SDOH items offer information that can help you tailor care plans, and discharge plans as well, to meet the specific needs of that individual resident.”
The new section R items will be especially impactful for discharge planning—and they have the potential to help skilled nursing facilities (SNFs) reduce hospital readmissions, says McCarthy. “If a resident has unstable housing (R0310), unstable utilities (R0330), unstable access to food (R0320A and R0320B), or unstable access to transportation (R0340), any of those situations can impact their recovery following discharge from the SNF. Knowing this information about the resident can help the IDT connect the resident and their family with the right community resources, and the IDT should benefit from having this information collected in one section where it’s easy to find and use.”
Review the timing of current SDOH interview items
When the existing slate of SDOH items launched in October 2023, many interdisciplinary team members didn’t initially understand what it means that these are resident self-report items, says McCarthy. “Even though the SDOH items are not scripted interviews like D0150 (Resident Mood Interview (PHQ-2 to 9)) where the item sets instruct assessors on exactly what to ‘say to’ or ‘ask’ the resident, you also have to gather resident self-report assessment data through interviews.”
Like other interviews, the SDOH interviews must be completed during the assessment reference period by the end of the assessment reference date (ARD), points out McCarthy. “In addition, you must do new SDOH interviews for each required assessment the same way that you do for the scripted interviews. You want to be sure that everyone involved is doing all required interviews timely for the current SDOH so that the addition of the new SDOH in section R will go more smoothly.”
McCarthy offers two examples of interview requirements for the current SDOH:
- Prospective payment system (PPS): A resident is admitted for skilled rehabilitation therapy services under Medicare Part A and then discharges home. “In this scenario, you have to do resident interviews by the close of the ARD to complete all seven SDOH items on the PPS 5-Day MDS,” she notes. “Then for A1250 (Transportation), B1300 (Health Literacy), and D0700 (Social Isolation), you also must do the same interviews again for planned discharges by the close of the ARD on the Part A PPS Discharge assessment (i.e., without carrying over information from the PPS 5-Day) to meet the MDS data collection requirements for the Skilled Nursing Facility Quality Reporting Program (SNF QRP).”
Note: On Oct. 1, 2025, A1250 will be replaced by the revised R0340 (Transportation), which will only be collected on the PPS 5-Day MDS for the SNF QRP. - Omnibus Budget Reconciliation Act (OBRA): A resident is admitted to live in the facility for long-term care. “The current SDOH items are active on all the OBRA item sets, and the interviews need to be completed by the close of the ARD for each required OBRA assessment, says McCarthy. “Only A1250 (Transportation) and B1300 (Health Literacy) are limited by the instruction ‘Complete only if A0310B = 01 [5-Day Scheduled Assessment] or A0310G = 1 [Planned/Type of Discharge] and A0310H = 1 [Yes/Is This a SNF Part A PPS Discharge Assessment].’ So, for example, you have to complete the interviews for A1005 (Ethnicity), A1010 (Race), A1110A (What Is Your Preferred Language?), A1110B (Do You Need or Want an Interpreter to Communicate With a Doctor or Healthcare Staff?), and D0700 (Social Isolation) on this resident’s standalone OBRA Admission assessment and then again on their standalone OBRA Quarterly and Annual assessments.”
Note: No section R items will be completed on standalone OBRA assessments. These items will completed “only if A0310B = 01 and A2300 minus A1900 is less than 366 days for the NC (Comprehensive) and NQ (Quarterly) item sets” or “only if A2300 minus A1900 is less than 366 days for the NP (PPS 5-Day) and SP (Swing-Bed PPS 5-Day) item sets,” according to the draft section R.
The following chart derived from the draft MDS version 1.20.1 item matrix and the SNF QRP Overview of Data Elements Used for Reporting Assessment-Based Quality Measures and Standardized Patient Assessment Data Elements Affecting Fiscal Year (FY) 2027 Annual Payment Update (APU) Determination sums up the basic OBRA and PPS reporting requirements for the SDOH items effective Oct. 1, 2025:
| SDOH Items on the MDS Effective Oct. 1, 2025 | Reported on Standalone OBRA Assessments! | Reported on PPS Assessments for the SNF QRP/APU Determinations | |
| PPS 5-Day A0310B=[01] | Part A PPS Discharge A0310H=[1] | ||
| A1005 (Ethnicity) | X | X | |
| A1010 (Race) | X | X | |
| A1110A (What Is Your Preferred Language?) | X | X | |
| A1110B (Do You Need or Want an Interpreter to Communicate With a Doctor or Healthcare Staff?) | X | X | |
| B1300 (Health Literacy) | Not completed on standalone OBRA assessments. Complete only if A0310B (PPS Assessment) = 01 (5-Day Scheduled Assessment) or A0310G (Type of Discharge) = 1 (Planned) and A0310H (Is This a SNF Part A PPS Discharge Assessment?) = 1 (Yes). | X | X |
| D0700 (Social Isolation) | X | X | X |
| R01310 (Living Situation)* | Not completed on standalone OBRA assessments. Complete only if A0310B (PPS Assessment) = 01 (5-Day Scheduled Assessment) and A2300 (Assessment Reference Date) minus A1900 (Admission Date (Date This Episode of Care in This Facility Began)) is less than 366 days for the NC (Comprehensive) and NQ (Quarterly) item sets. Or Complete only if A2300 minus A1900 is less than 366 days for the NP (PPS 5-Day) and SP (Swing-Bed PPS 5-Day) item sets. | X | |
| R0320A (Food: Within the Past 12 Months, You Worried That Your Food Would Run Out Before You Got Money to Buy More)* | The completion instructions listed above for R1310 apply to all section R items. | X | |
| R0320B (Food: Within the Past 12 Months, the Food You Bought Just Didn’t Last, and You Didn’t Have Money to Get More)* | The completion instructions listed above for R1310 apply to all section R items. | X | |
| R0330 (Utilities)* | The completion instructions listed above for R1310 apply to all section R items. | X | |
| R0340 (Transportation)*, ** | The completion instructions listed above for R1310 apply to all section R items. | X | |
* New effective Oct. 1, 2025. Data collection for FY 2027 SNF QRP annual payment update (APU) determination will occur Oct. 1, 2025 – Dec. 31, 2025 for these items. Then, these items will transition to the standard annual data collection for FY 2028 forward.
** R0340, which will only be collected on the PPS 5-Day MDS for the SNF QRP, will replace the current transportation item (A1250), which is collected on both the PPS 5-Day and the Part A PPS Discharge assessment. A1250 data collection ends on Sept. 30, 2025.
! Standalone OBRA assessments that these SDOH must be reported on include the following:
- OBRA Admission: A0310A (Federal OBRA Reason for Assessment) = 01 (Admission Assessment), A0310B (PPS Assessment) = 99 (None of the Above), A0310F (Entry/Discharge Reporting) = 99 (None of the Above), A0310G (Type of Discharge) = ^ (Blank due to a Skip Pattern), A0310H (Is This a SNF Part A PPS Discharge Assessment?) = 0 (No)
- OBRA Quarterly: A0310A = 02 (Quarterly Review Assessment), A0310B = 99, A0310F = 99, A0310G = ^, A0310H = 0
- OBRA Annual: A0310A = 03 (Annual Assessment), A0310B = 99, A0310F = 99, A0310G = ^, A0310H = 0
- OBRA Significant Change: A0310A = 04 (Significant Change in Status Assessment), A0310B = 99, A0310F = 99, A0310G = ^, A0310H = 0
- OBRA Discharge: A0310A = 99 (None of the Above), A0310B = 99, A0310F = 10 (Discharge Assessment – Return Not Anticipated) or 11 (Discharge Assessment – Return Anticipated), A0310G = 1 (Planned) or 2 (Unplanned), A0310H = 0
Make sure staff understand when other documentation sources are allowed
In general, CMS expects the current SDOH resident self-report items to be coded based on resident interview, says McCarthy. “The agency only allows limited use of other sources of information, such as family interviews or documentation in the medical record, for the seven current SDOH resident interview items.”
For example, medical record documentation can be used to support A1005 (Ethnicity), A1010 (Race), and A1250 (Transportation) only if the resident is unable to respond, and no family member, significant other, or guardian or legally authorized representative provides a response, points out McCarthy. “If the resident declines to respond, you cannot use any other sources of information to code these items.”
A1110A (What Is Your Preferred Language?) is the only outlier among the section A SDOH, adds McCarthy. “The coding instructions for A1110 in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) on pages A-23 – A-24 in chapter 3 tell assessors to interview the resident first; allow the interview of a representative if the resident is unable to respond even with the help of an interpreter; and allow documentation in the medical record to be used ‘if neither the resident nor a family member, significant other, nor guardian/legally authorized representative source is able to provide a response for this item.’”
However, only resident interview can be used to support B1300 (Health Literacy) and D0700 (Social Isolation), stresses McCarthy. “The coding instructions for both items state (on pages B-15 and D-18, respectively, in chapter 3), ‘This item is intended to be a resident self-report item. No other source should be used to identify the response.’”
The bottom line is that IDT members must do a good job timing the SDOH resident interviews and, when necessary, family/representative interviews because using documentation from the medical record isn’t always allowed, says McCarthy. “You want to ‘get your house in order’ now so that when the new and revised section R items are added on Oct. 1, 2025, you will be in pretty good shape to gather that additional SDOH assessment information. You may need to work with the DNS or other nurse leaders to ensure that staff prioritize conducting timely interviews for the SDOH items.”
Work on reducing unnecessary SDOH dashes
Having a strong assessment process that limits unnecessary dashing of those SDOH items that allow dashes is especially important for Medicare Part A residents, notes McCarthy. “SDOH items that have to be dashed because your team members aren’t doing these resident interviews—or they are doing them too late (i.e., after the ARD)—can affect your facility’s MDS data submission rate for the SNF QRP.”
Effective Jan. 1, 2024, for the FY 2026 program year, SNFs must report 100 percent of the required MDS data on at least 90 percent of the required assessments as part of the data submission threshold requirements they have to meet to avoid a 2 percent penalty in their Part A payments, says McCarthy. “So, you want to be doing the current SDOH items correctly now and be as prepared as possible for what is coming on Oct. 1, 2025.”
Note: Find the FY 2026 and FY 2027 MDS data submission requirements here and here, respectively. Learn more about the data submission deadlines for both fiscal years here.
Collaborate with the DNS to address resident and staff concerns
“Some SDOH can cause strong reactions among residents, their families, or the staff members who collect the data,” acknowledges McCarthy. “For example, they may worry about how the SDOH data will be used. CMS acknowledges some of these concerns in the RAI User’s Manual. The Steps for Assessment: Interview Instructions for A1005 (Ethnicity) and A1010 (Race) on pages A-17 and A-20, respectively, in chapter 3 discuss how to make residents more comfortable answering.”
Other potential issues that may impact data collection include whether there is a trusting relationship between the staff conducting the interviews and the resident or family member and whether staff have enough time to do the interviews timely (i.e., prior to the ARD), according to “Clinician and Patient Perspectives on the Exchange of Sensitive Social Determinants of Health Information” from the Oct. 31, 2024, JAMA Network Open. “If you are having problems obtaining accurate, timely SDOH information, you should work with the DNS to determine whether there are systemic issues other than staff education that need to be addressed,” suggests McCarthy.
Note: CMS also has released the draft MDS data specifications v3.10.0 for Oct. 1, 2025, which include the news that the agency plans to make the dash (-) an allowed value for the D0150 (Resident Mood Interview (PHQ-2 to 9)) symptom frequency items (i.e., column 2). Find the data specs here. The Adobe Acrobat (pdf) file MDS Data Specs Report (V3.10.0) DRAFT 09-25-2024 – Section D in the MDS 3.0 Data Specs PDF Files subfolder includes information about how the Total Severity Score will be calculated if one, two, or three or more of these items are dashed.
| The New Draft Section R (Health-Related Social Needs) Complete only if A0310B = 01 and A2300 minus A1900 is less than 366 days for the NC (Comprehensive) and NQ (Quarterly) item sets. Or Complete only if A2300 minus A1900 is less than 366 days for the NP (PPS 5-Day) and SP (Swing-Bed PPS 5-Day) item sets. Added Items: |
| R0310 (Living Situation) What is your living situation today? 0. I have a steady place to live 1. I have a place to live today, but I am worried about losing it in the future 2. I do not have a steady place to live 7. Resident declines to respond 8. Resident unable to respond |
| R0320 (Food) A. Within the past 12 months, you worried that your food would run out before you got money to buy more. 0. Often true —> Skip to R0330, Utilities 1. Sometimes true —> Skip to R0330, Utilities 2. Never true 7. Resident declines to respond 8. Resident unable to respond B. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. 0. Often true 1. Sometimes true 2. Never true 7. Resident declines to respond 8. Resident unable to respond |
| R0330 (Utilities) In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home? 0. Yes 1. No 2. Already shut off 7. Resident declines to respond 8. Resident unable to respond |
| R0340 (Transportation) In the past 12 months, has the lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? 0. Yes 1. No 7. Resident declines to respond 8. Resident unable to respond |
Note: The existing transportation item (A1250) will be deleted and replaced by R0340.
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