Social Determinants of Health and New MDS Items

September 29, 2023


CMS has updated MDS 3.0 to include multiple items related to Social Determinants of Health (SDOH). The items will impact SNF Quality Reporting Measures and will be reported publicly. The data collection of SDOH data will assist CMS to understand how social determinants of health impact long-term care facilities and residents.

Capturing standardized SDOH data helps to:
1. Understand factors at the individual, community, and population levels.
2. Improve quality of care and health outcomes.
3. Document and track health disparities.
4. Allow for comparison of SDOH data within and across post-acute care settings.
5. Support the collecting/sharing of data across certification, policy and coordination agencies and stakeholders.

This presentation will cover the 6 new Social Determinants of Health plus one non-SDOH new item. The Social determinants of health include Race, Ethnicity, Language, Transportation, Social Isolation, and Health Literacy. The non-SDOH item will include Medication reconciliation on discharge to another provider or to home and how that medication reconciliation is communicated.These items are critical to individualized person-centered care planning and the provision of culturally competent care. The medication reconciliation on discharge is new and important to help our residents have safer discharges. These new measures are also Post-acute cross-setting measures.

Learning Objectives:
1. State one example of how knowledge of the residents’ transportation issues from the last 6 months to one year can impact discharge planning.
2. Report how information learned regarding a resident’s health literacy can inform providers about risks to the resident prior to admission and after discharge.
3. Identify one strategy to improve residents’ reported social isolation while in the SNF.
4. Explain how collecting racial and ethnic background information can assist with culturally competent care planning.



Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter, providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

  • 1.5 hours for Licensed Nurses
  • 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on September 30, 2025.


Hansen Hunter & Co. P.C. clients are invited to access any of our webinars for free by contacting Allison Johnson at our office at 503.244.2134 to receive your free registration code.


  • This nursing continuing professional development activity was approved by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Enduring material: To meet the requirements for these contact hours, you must watch the entire recorded presentation as well as answer and submit the post-test evaluation that is provided as a link along with the link to your webinar which you will receive via email after completing your purchase.