Social Determinants of Health: Determining patient SDoH, coding best practices, strategies and resources for success

ECLAT Health Solutions can help with all of your SDoH coding questions, concerns, and needs

What happens outside a patient’s typical point of care can have a tremendously significant impact on their overall health and well-being; factors that until quite recently were dismissed or overlooked. Many believe that doing so could prove harmful or lead to incomplete care provision and diminish care outcomes for some of the most vulnerable populations.

Factors now known as social determinants of health (SDoH) include everything from where a patient lives and their housing condition, and what they eat, drink or smoke to their economic status and if they have a support group, contribute to patient health outcomes. When taken into account and monitored, SDoHs can help guide a complete patient care path.

Each of these variables can have a significant impact on an individual's health. According to the National Academy of Medicine, for example, medical care accounts for only 10% to 20% of all health outcomes. The remaining majority may tie directly to environmental and socioeconomic factors and individual behavior. All of these things factor into a patient’s overall picture of health or lack thereof.

Determining a patient’s SDoH and their impacts on care

Identifying patient risk is about gathering data regarding specific factors within and affecting an individual's lifestyle. These reported factors can lead to intervention. When factoring in potential SDoH risks, all care team members must draw from a patient's background and environmental influences.

Additional factors impacting a patient’s SDoH are their census data, payer information, and self-reported information, of course. Some technologies can help collate this patient information.

According to Healthy People 2020, SDoH is "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."

Five SDoH domains:

• Economic stability
• Education
• Health and healthcare
• Neighborhood and built environment
• Social and community context

The United States Office of Disease Prevention and Health Promotion lists the following specific examples of social determinants:

• Availability of resources to meet daily needs (e.g., safe housing and local food markets)
• Access to educational, economic, and job opportunities
• Access to healthcare services
• Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
• Transportation options
• Public safety
• Social support
• Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
• Exposure to crime, violence, and social disorder
• Socioeconomic conditions
• Residential segregation
• Language/Literacy
• Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)

Economics can have a direct impact on an individual’s long-term well-being. For example, in incidents where individuals spend 50% or more of their income on housing, their health can suffer as they make doctor’s visits, eating well, and exercise less of a priority. Carrying this example forward, these same individuals, if they have children or minors in the home, may be less likely to address or speak to issues or problems they may be going through, which can impact the health and well-being of the minor.

The care management lifecycle focuses on these and several other factors, identifying potential socioeconomic or environmental elements that can impact, exacerbate or encourage poor behavior or lead to less-than-ideal health outcomes. SDoHs are vital to healthy patient outcomes for many reasons. Here are a few of the most prevalent, according to the Alliance for Health Policy¹ :

• 1 in 5 Americans lives in a neighborhood with high rates of crime, pollution, inadequate housing, lack of jobs, and limited access to nutritious food (source).
• Asthma is more prevalent in minority and low-income communities, affecting 11.2% of those below 100% of the poverty level, compared to 7.3% of those with incomes over 200% of the poverty level (source).
• People who are socially isolated have a death rate 2 to 5 times higher than people with close relationships to friends, family, and community (source).

The first step for caregivers when attempting to address or document SDoH in their patient community is learning about the patient's experience. Understanding social factors that impact patients can determine the best strategies for addressing SDoH factors.

Strategies for addressing SDoH

There are several quality resources for addressing SDoH, but one of the best strategic overviews may be provided by Rural Health Information Hub. While some of the following resources are excellent, we're by-no-means giving a complete or comprehensive list here, instead offering initial guidance and a few steppingstones so you can better address, process, and document SDoH.

One quality SDoH resource is provided by the Health Resources & Services Administration (HRSA) is the Area Deprivation Index (ADI). The ADI offers assessment tools and guidance related to documenting and evaluating patient income, education levels, job history or professional status, and even quality of individual’s housing down to the neighborhood level.

Likewise, as noted by Rural Health Information Hub, the National Equity Atlas provides demographic data, economic benefits of equity at the city, state, and national level, as well as other racial information. Another exceedingly valuable resource is the Opportunity Index, which has national, state, and county data based on economic opportunity, education, healthcare, and other factors. Local factors are comparable to the national average.

Finally, the American Academy of Family Physicians developed a screening tool -- a one-page screening form focused on lack of transportation, social isolation, food insecurity, financial strain, housing problems, and household violence. It’s a solid resource for any medical practice to use when starting an SDoH screening program.

It's worth noting that screening for social needs in the medical setting is usually acceptable to patients and can lead to better access to community resources and the resolution of social needs no matter your ultimate strategy or the direction you take with your SDoH program.

Addressing SDoH: A real-world example

Indiana University Health recently invested $100 million ² in a fund to address critical health issues across the state and is making grants to address social issues affecting health outcomes across the state. Grants from the program are being used to develop strategies in four areas, including healthy living, educational attainment, workforce development, and place-based solutions to improve neighborhoods and alleviate poverty.

Through the effort, so far, Indiana University Health is funding a healthy families program in Indianapolis, a diversion center dealing with opioid abuse in Bloomington, a neighborhood revitalization project in Muncie, and an undertaking between faith congregations and hospitals in Central Indiana to better care for socially isolated people with chronic health issues.

It also launched an initiative called One Measure ³ that encompasses and tracks all the community-facing IU Health programs that influence healthy living habits.

If you want to hear more real-life examples like these, we highly encourage you to tune in to ECLAT's upcoming webinar: "Social Determinants of Health in 2021: Healthcare Considerations for the Most Vulnerable." Subject matter experts Marie A. Thomas, MHA, RHIT, CCS, CCDS, COC, Kara Carlisle, RHIA, and Evelyn Santos, CCS, are eager to dive in to demonstrate how SDoH initiatives are getting us closer towards health equity.

Coding for SDoH

Coding SDoH, while requiring specialized training and experience, varies only slightly from other medical coding services' best practices. If your medical practice, health system, or other care organization begins tracking and document patient social determinants, the encounters employ the expanded ICD-10-CM codes included in categories Z55-Z65

Through these codes, you can identify persons facing health hazards, as self-reported, because of their socioeconomic and psychosocial circumstances. A short description of each code in the SDoH subset follows:

• Z55 – Problems related to education and literacy
• Z56 – Problems related to employment and unemployment
• Z57 – Occupational exposure to risk factors
• Z59 – Problems related to housing and economic circumstances
• Z60 – Problems related to the social environment
• Z63 – Other problems related to a primary support group, including family circumstances
• Z64 – Problems related to certain psychosocial circumstances
• Z65 – Problems related to other psychosocial circumstances

The American Academy of Pediatrics published a quick reference to social determinants of health coding, which provides added detail for several "determinants" and a corresponding ICD-10 CM code description. It offers additional detail than that listed above.

Finally, from the authority itself, the Department of Health and Human Services (HHS) published an illustrative guide, "Using Z Codes: The Social Determinants of Health (SDoH), Data Journey to Better Outcomes, which is updated regularly. The guide is step-based, easy to read, illustrative, and colorful, and provides links for questions regarding SDoHs.

HHS recommends that coding professionals follow the ICD-10-CM coding guidelines, using the CDC National Center for Health Statistics ICD-10-CM Browser tool to search for ICD-10-CM codes and information on code usage. Coding team managers also should review codes for consistency and quality. All participating health organizations should assign all relevant SDoH Z codes to support quality improvement initiatives, HHS advises.

Despite these resources and other helpful guidance available for free, implementing a social determinant of health program – then coding these data appropriately – can be a challenge for any medical practice or health system. If you find that you need help, guidance, or council along the way, ECLAT Health Solutions is here to help.

ECLAT can help with all SDoH coding audits

ECLAT Health Solutions has worked with some of the most prestigious health organizations in the nation to ensure they document their SDoHs accurately and adequately. As a global healthcare partner to hundreds of healthcare organizations across the United States, ECLAT’s team of medical coding services professionals, which is accredited by AAPC and AHIMA, has extensive experience in coding specialties for various types of medical practice settings.

We understand how crucial proper medical coding services are to each patient but also to the financial health of each healthcare facility's revenue cycle. Thus, all codes must be accurate, secure, and efficient to ensure healthy revenue and compliance.

ECLAT's proprietary 3-Tier Quality Assurance process identifies and fixes any coding and compliance errors before it’s too late. Our process is designed to provide clients with the peace of mind they deserve and to guarantee that our coding is always accurate.

To meet your practice's or health system's needs -- and provide you with the utmost value -- our expert coders are trained vigorously in processing SDoH codes and all other elements of the code set to ensure accuracy and timely submission to payers.

Additionally, ECLAT's world-class medical coders receive the highest level of ongoing continued education and training in the latest coding practices and methodologies -- delivering 95% accuracy or greater in all of our submitted claims.

ECLAT Health Solutions provides outsourced medical coding services for hospitals, physician offices, and other healthcare providers. Our SDoH services are available nationwide, and we offer a 24-hour turnaround time.

Social Determinants of Health in 2021:

Healthcare Considerations for the Most Vulnerable

References:

[1] "Chapter 7 – Social Determinants of Health"; Alliance for Health Policy; Aug. 31, 2017; https://www.allhealthpolicy.org/sourcebook/social-determinants-of-health/

[2] "IU Health invests $100M to tackle social determinants of health"; Mackenzie Bean; Nov. 19, 2019; https://www.beckershospitalreview.com/care-coordination/iu-health-invests-100m-to-tackle-social-determinants-of-health.html

[3] "IU Health creates community impact fund with $100M investment"; Nov. 3, 2019; https://iuhealth.org/thrive/iu-health-creates-community-impact-fund-with-100m-investment