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Health Care Review: Social Determinants of Health — A Positive Impact on Care Delivery Models
By Selena Chavis
Social Work Today
Vol. 19 No. 6 P. 28

There’s a new buzz phrase taking health care by storm: social determinants of health (SDOH), though it is hardly new to social workers. Linked by researchers to approximately 80% of overall health, SDOH are defined by Healthy People 2020 as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

SDOH represent the nonclinical factors that can minimize the effectiveness of care delivery. Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, principal with EFS Supervision Strategies, notes that that health care systems at large are increasingly recognizing the opportunity to prioritize SDOH, especially since evidence points to a notable return on investment—up to 300% for health care organizations. For example, a recent Connance survey links 50% of readmissions to factors such as transportation and home instability risk.

“Organizations are hemorrhaging wasted dollars by not addressing the SDOH,” Fink-Samnick says. “The dollars are out of control and the majority of organizations have a program, initiative, collaboration, or merger in the works to address them.”

As the industry begins to wrestle with how best to address SDOH to elevate care delivery and quality outcomes, one area of considerable interest to social workers is quickly surfacing: new codes to capture these important elements of health.

While Z codes offer a starting point, a new collaboration between UnitedHealthcare and the American Medical Association (AMA) hopes to deliver a more expansive set of codes to identify and address critical social and environmental factors. Building on work initiated by UnitedHealthcare, the two organizations are working together to standardize how data are collected, processed, and integrated.

“We have been working in the SDOH space for over four years now,” says Sheila Shapiro, national vice president of population management and clinical innovation for UnitedHealthcare, noting that the organization found that many members were self-identifying their SDOH needs. “As we began to gather that info, it became clear that there was not a common way to capture and codify that data to bring it into a health care system environment.”

Since UnitedHealthcare began its SDOH quest, 1.5 million Medicare Advantage members (out of 5 million total) have self-identified at least one social barrier to care, and the organization has made more than 800,000 referrals to social and government agencies. This effort, according to Shapiro, equates to a value of more than $250 million.

“It grows every month because we now have a methodology to capture it and give it a voice in our system,” Shapiro says. “We know we have not touched every member to determine whether they have that need. I think we have just begun to think about how SDOH has a place in whole-person health.”

The Collaboration: A Deeper Look
Through their collaboration, UnitedHealthcare and the AMA are supporting the creation of nearly two dozen new International Classification of Diseases, 10th revision (ICD-10) codes related to SDOH. By combining traditional medical data with self-reported SDOH data, the codes trigger referrals to social and government services to address an individual’s unique needs, connecting them directly to local and national resources in their communities.

“We know this has to be a collaborative effort if we are going to address SDOH on a national basis,” Shapiro points out. “Our pairing with the AMA and their Integrated Health Model Initiative group will allow us to collaborate on these data standards and portability. We have many other partners also engaged in this work with us, and we know that our network shares that same vision to help people address all aspects of their health.”

Through the effort, Shapiro says the two organizations wanted to fully leverage the existing codes related to SDOH before creating something new. “There are 15 ICD-10 codes for some SDOH, but in the work we have done, we saw a need to begin a discussion to expand these to at least the 23 key areas where we saw members reporting to us that they had a need or where we were making a referral,” she explains.

After identifying the needed codes, the collaborative made a recommendation to the ICD-10 Coordination and Maintenance Committee during the first week of March. Following a 60-day open public comment period, the committee will advise next steps on the recommendation. The earliest the new codes would be available for use is October 2020. In the meantime, Shapiro says that UnitedHealthcare is engaging with partners to begin educating and communicating with stakeholders about the codes currently available and the future possibilities.

Beyond Z Codes
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, an independent consultant specializing in health information mangement, coding, and compliance, believes that expanding beyond the current Z codes is necessary to support quality improvement. “I think these [new] codes are key. The impact of these particular codes may determine future health care prevention efforts and coverage,” she notes.

Bryant points to recent efforts by the American Hospital Association (AHA) to promote more mainstream use of Z55–Z65, which identify persons with potential health hazards related to socioeconomic and psychosocial circumstances. In early 2018, for example, the AHA Coding Clinic published advice that allows the reporting of codes from categories Z55–Z65, based on information documented by all clinicians involved in the care of the patient. This recommendation, which was approved by the ICD-10 Clinical Modification Cooperating Parties, went into effect in February 2018.

Fink-Samnick says that this move represented an important strategic direction for the industry, although expansion beyond the Z codes and the current list of 88 categories and subcategories is needed. “Their focus on potential health hazards related to socioeconomic and psychosocial circumstances is broad—and a broad swipe at that,” she says.

While the Z codes have been a welcome addition, some industry experts believe they can be expanded. “UnitedHealthcare wants to go further while homing in on the costliest outliers,” Fink-Samnick says. “For example, transportation is missing from the list, and many experts know this area is as vital an issue to address as food insecurity.”

Notably, a study published in the March 2018 issue of JAMA Internal Medicine found that 3.6 million people missed appointments due to transportation issues, a concern that can be easily remedied through such services as Uberhealth and Lyft, according to Fink-Samnick.

Barriers to Forward Momentum
Fink-Samnick points out that health care organizations can only extract the full value of an expanded code set if they optimize its use.

“The industry needs to make better use of the established ICD-10 Z codes in place, including documentation of the SDOH by the entire interprofessional care team,” she emphasizes, adding that optimal use requires engaging not only physicians but also nurses, social workers, case managers, nutrition, respiratory therapy, rehabilitation, pharmacy, and other allied professionals. “It is just a year since the AHA announced the mandate that nonclinical documentation would be accepted to substantiate the presence of the SDOH and the need to use them. I’d be curious to see how many organizations are leveraging the potential of this option and what reimbursement looks like at this point.”

Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance with the American Health Information Management Association, says that the lack of a standardized method for collecting information may pose problems as the industry tries to draw insights from the data produced by an expanded code set.

“Depending on how the health question is worded on different health risk assessments, the answer might be different,” she explains, pointing out that some of the information may be self-reported by patients in arbitrary ways. “If you only standardize the code and the information feeding into them is not standardized, the data are not all that useful. There still needs to be standardization around how the information is collected.”

While challenges exist, Bowman stresses the importance of SDOH going forward. “I’m not sure in the long run that it may be feasible to collect everything people want to collect,” she says. “I do think there is opportunity to expand the code set. Where that line should be drawn is still up in the air.”

Fink-Samnick suggests that the face of the SDOH will continue to change rapidly, bringing more populations into the fold. Those currently impacted include victims of natural and man-made disasters; adults living with disabilities; homeless veterans; persons dealing with sudden shifts in the economy, loss of income from business closures, and government shutdowns; and residents of rural health regions.

Shapiro emphasizes that the current effort is simply the beginning. “Twice a year, the ICD-10 committee meets and providers and other organizations make recommendations to enhance and improve those codes because they are critical to diagnosis as well as reporting,” she says. “We believe this is a starting place for really coming together around a common code set and common language to capture and report and analyze as well as assist each person at a time with a personalized response.”

Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various publications, covering everything from corporate and managerial topics to health care.