What Are the Social Determinants of Health?
The World Health Organization (WHO), US Department of Health and Human Services (HHS) – Office of Disease Prevention and Health Promotion, and the Centers for Disease Control and Prevention all have all adopted the definition of Social Determinants of Health “as the nonmedical factors that influence health outcomes”. “They are the conditions in which people are born, grow, work, live, learn, worship and age that profoundly shape their health status and quality of life.” Contained within Social Determinants of Health (SDOH) are systemic social inequities that lead to poor health. The CDC has categorized the 5 domains encompassing the SDOH and provided examples of conditions within each domain:
- Economic Stability – employment status, poverty, lack of stable housing, homelessness, limited access to healthy food, lack of food security, lack of stable utility services.
- Education Access & Quality – level of education attainment, language and literacy, early childhood education and development.
- Health Care Access & Quality – access to primary care, health insurance coverage, health literacy.
- Social and Community Context – civic participation, discrimination/segregation, community cohesion, workplace conditions, incarceration, social support, loneliness.
- Neighborhood and Built Environment – unsafe home environment, community violence, availability of transportation, crime rate, access to clean air and safe drinking water.
Why Has CMS and Commercial Payers/Insurers Required Mandatory Screening and Documentation of SDOH in the EHR?
As of January 1, 2024, CMS is now requiring healthcare organizations to screen for five social risk factors. The required five SDOH domains are: food insecurity, interpersonal safety, housing insecurity, and utilities.
The SDOH reporting requirements apply to hospitals and health systems that admit patients. The collection period will run through 2024; healthcare organizations will have until May 15, 2025, to submit the data to CMS. CMS suggests that healthcare teams review and consider utilization of the most widely used, health-related social needs (HRSNs) screening tools such as those on the Social Interventions Research and Evaluation Network (SIREN) website. Of note, organizations that have participated in the voluntary submission program may have assessment and screening tools already embedded into the EHR. In addition, it is important to note that the SDOH reporting mandate is part of a larger CMS initiative to advance health equity, expand coverage, and improve care for underserved and disadvantaged communities.
CMS is also introducing two new inpatient quality reporting measures in 2024 surrounding compliance with screening for SDOH and positive rate for SDOH.
The CMS FY 2025 Inpatient Prospective Payment System (IPPS) Final Rule introduces three new ICD-10 Z codes (diagnosis codes), addressing homelessness from various prospectives. The codes, Z59.00 (homelessness, unspecified), Z59.01 (sheltered homelessness), and Z59.02 (unsheltered homelessness), are now designated as complication or comorbidity (CC), recognize the critical line between socioeconomic conditions and health conditions. For FY 2024, homeless Z codes will now code as a “CC” or complication or comorbidity to be included in the MS-DRG assignment . CMS has done this to recognize homelessness as an indicator of increased resource utilization in the acute hospital setting; if these Z codes are documented and reported as secondary diagnosis, diagnosis can result in higher payments to hospitals.
Utilization of ICD-10-CM codes from categories Z55-Z65 are used to identify nonmedical factors that may influence a patient’s health status. These codes identify in the patient’s medical record issues related to a patient’s socioeconomic situation, including the conditions noted earlier, such as education and literacy, employment, housing, etc. Z codes became available in fiscal year 2016, but their adoption has been slow. CMS reports that health care providers used Z codes for 1.6% of Medicare fee-for-service beneficiaries in 2019.
Providers must assess and document SDOH as it affects the plan/complexity of care, but also tie the SDOH to the status of the patient’s current health conditions. This allows coders to assign the correct Z codes.
However, codes from categories Z55-Z65 can be assigned based on social needs/information documented by all clinicians involved in the care of the patient, this includes nursing, social workers, community health workers, case managers, therapists, behavioral health technicians or other providers of which coding professionals are able to utilize to correctly assign the appropriate Z codes.
It is important to note that Z code category assignments are also utilized in the ambulatory/clinic patient EHR which may increase payment under the FY 2024 Physician Fee Schedule Final Rule as well. A new, finalized stand alone “G” code, G0136, has been added to pay for administering an SDOH risk assessment, no more than once every 6 months in the ambulatory/clinic setting.
Robust social needs data is critical to hospitals and ambulatory clinics’ efforts to improve the health of their patients and communities. And, employing standardized approaches to outpatient and acute care screening for, documenting and coding social needs will enable healthcare systems and organizations to:
- Track the social needs that impact patients, allowing for personalized care that addresses patients’ medical and nonmedical needs.
- Aggregate data across patients to determine how to focus a SDOH strategies; and
- Identify population health trends to guide targeted, effective partnerships.
At the national level, including social needs data in hospital claims will inform and enable system-wide research to facilitate a more acute understanding of the various health-related social needs of patients and communities across the country. Federal policy and programs could more effectively customize their actions to meet those needs. In addition, as payment shifts from volume (fee for service) to value, having claims data related to social needs can support policy and payment reforms, including appropriate risk-adjustments.
Nurses, in their role as patient advocates, in addition to focusing on holistic practice, have the unique advantage of providing care across the health continuum which enables them to identify needs and adapt practice for each individual patient to ensure optimal health outcomes. As stated earlier, over 50% of an individual’s health outcomes are determined by factors that are encompassed in the SDOH. It is imperative that nurses, as clinicians, recognize that these needs must be assessed and prioritized equally with the medical aspects of care and integrated into nursing practice.
Key takeaways for clinical nurses¹:
- Learn more about the organization policies and procedures for SDOH.
- Review your EHR to identify where SDOH is being documented and collected and the best locations to review the data.
- Encourage colleagues to have discussions with patients to understand their level of comfort on sharing SDOH information.
- Participate, support, and advise organizational plans to implement SDOH screening and documentation into nursing workflows.
- Identify opportunities to conduct a nursing inquiry for SDOH interventions.
- Establish ways to triage support based individual responses to SHOH-related questions by involving interdisciplinary team members such as social services, case management, nutritional services, and mental health professionals.
For nurse leaders and nurse informaticists¹:
- Help support and promote the importance of SDOH through policy and workflow changes at your organization.
- Participate in committees and groups at a local, state, and national level to advance standards, policies, and incentives for the collection, use and sharing of SDOH data.
- Collaborate and establish/further partnerships within the community to support the identified needs of patients.
References
- Tiase, V., Crookston, C., Schoenbaum, A., & Valu, M. Nurses’ role in addressing social determinants of health. (2022). Nursing 52(4): 32-37. https://journals.lww.com/nursing/pages/articleviewer.aspx?year=2022&issue=04000&article=00010&type=Fulltext
https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-4.pdf
https://health.gov/healthypeople/priority-areas/social-determinants-health
https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1\
©2022 American Hospital Association – January 2022; www.aha.org
