Addressing Social Determinants of Health

Addressing Social Determinants of Health (SDOH) requires healthcare workers to think beyond the traditional medical interventions that they are used to discussing with patients. It requires having a network of outside resources that the team collaborates with and adding more social services to address the root causes of health concerns. It requires being aware of unconscious bias in our thought patterns and how to overcome these biases.  And it requires SDOH data to be collected and tracked throughout patients’ lifetime just as any other vital sign or lab value is tracked. Addressing SDOH has shown to improve many outcomes, not the least of which is the decrease in provider stress by having needs that lead to poor health outcomes addressed. 

Requirements for MSSP ACOs, ACO REACHs, and PCF Participants

Both MSSP ACOs and ACO REACHs, as well as participants in the Primary Care First (PCF) model, all have differing requirements for reporting on SDOH. For MSSP ACOs, the health equity adjustment started in 2023 and is adjusted based on the number of patients living in high area deprivation index (ADI), dual eligible status, and those who receive a low-income subsidy. ACO REACH programs are required to submit a health equity plan to address, or at this time at least plan to address, health equity disparities, submission of SDOH and sociodemographic data, and they can receive a health equity benchmark adjustment (HEBA). PCF at this time is only required to have a community-based organization (CBO) network available to address the SDOH needs identified. 

SDOH Training

Before any other steps are taken, training on how to ask questions about SDOH in a culturally and linguistically appropriate manner is essential. In this training, the team should become aware of their unconscious biases as well as how to be sensitive to how other cultures may need to be assessed in a way that is not unintentionally disrespectful. After training the team, ensure that your organization is using one of the three CMS approved tools to collect SDOH data. Acclivity uses both the SDOH North Carolina Health Screening Tool and the AHC Health-Related Social Needs (HRSN) Screening Tool to allow our clients to have the option of choosing the tool that works best for their programs. 

Z Codes for SDOH Data Collection

Once the SDOH data is collected, it is essential to document the Z codes for SDOH in the patient record. CMS updated the Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes in October 2023 when more detailed Z codes were added. These Z55-65 diagnoses being present inside of the patient record allows for accurate tacking of needs for your population as well as patient level tracking. Adding the SDOH Z codes to the claims as a matter of policy in the practice is a way of encouraging the providers to review the SDOH assessments and addressing these needs. Adding the Z codes to the claim should also encourage the billing providers to have increased awareness of these issues on the patients’ health status and discuss potential interventions with the patients such as chronic care management (CCM) services, social work referral, home health care, and to review the status of these identified SDOH needs on subsequent provider contacts.

Use of the Z codes in the EHR and on claims also assists with creating care plans in the EHR to address the identified needs. Interventions that can be added to the care plan include use of community health workers, contact with the CBOs in the area, appropriate educational materials provided, and other needed interventions to mitigate the impact of the areas of HRSN. Individualized care plans for the identified HRSN also allows for tracking of completion of the interventions and documentation of progress toward goals at each encounter with the patient. As with any identified health need, tracking the effectiveness of the interventions on the problem area is essential. Use of the SDOH assessment at each visit and discussing changes in the impact allows for individual changes to the care plan. The Z codes may be resolved – by securing ongoing nutritional support, housing support, and transportation, as examples – ongoing, or not yet started. Organizationally, the interventions can be evaluated by monitoring for decreased use of the ED, especially for potentially avoidable reasons, decreased overall utilization, and effectiveness of the CBOs in the organization’s network. The ACOs that I work with who have a robust CCM program and higher referrals to social work and additional lower cost, but highly effective, interventions have found that the more they invest in these areas, the better their performance on all metrics in their program. Additionally, addressing SDOH can also decrease overall provider stress by managing the root causes, or exacerbating factors, of a patient’s health status with the appropriate interventions.

While assessing and addressing SDOH and HRSN seem like yet another thing to add to the list of tasks, the improvement in all areas of your organizational performance makes this one of the most essential areas to invest time and resources. Ask us how we can help you with SDOH assessing and tracking today!

For additional help or more information set up a quick meeting, or read more on our SDOH Page.

Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions