Unlocking the Social Determinants of Health

By Selena Chavis for For the Record

An industry collaboration recently proposed codes designed to better support whole-person care.

There’s a new buzz phrase taking health care by storm: social determinants of health (SDOH). 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.”

In a nutshell, 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 the industry at large is increasingly recognizing the opportunity to prioritize SDOH in care delivery, 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 need 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 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 HIM, 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-CM 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.

The current scope of Z55–Z65 addresses the following:

• Z55 — Problems related to education and literacy: Illiteracy, schooling unavailable, underachievement in a school, educational maladjustment, and discord with teachers and classmates;
• Z56 — Problems related to employment and unemployment: Unemployment, change of job, threat of job loss, stressful work schedule, discord with boss and workmates, uncongenial work environment, sexual harassment on the job, and military deployment status;
• Z57 — Occupational exposure to risk factors: Occupational exposure to noise, radiation, dust, environmental tobacco smoke, toxic agents in agriculture, toxic agents in other industries, extreme temperature, and vibration;
• Z59 — Problems related to housing and economic circumstances: Homelessness; inadequate housing; discord with neighbors, lodgers, and landlord; problems related to living in residential institutions; lack of adequate food and safe drinking water; extreme poverty; low income; insufficient social insurance; and welfare support;
• Z60 — Problems related to social environment: Adjustment to life-cycle transitions, living alone, acculturation difficulty, social exclusion and rejection, target of adverse discrimination and persecution;
• Z62 — Problems related to upbringing: Inadequate parental supervision and control, parental overprotection, upbringing away from parents, child in welfare custody, institutional upbringing, hostility toward and scapegoating of child, inappropriate excessive parental pressure, personal history of abuse in childhood, personal history of neglect in childhood;
• Z62.819 — Personal history of unspecified abuse in childhood, parent-child conflict, and sibling rivalry;
• Z63 — Other problems related to primary support group, including family circumstances: Absence of family member, disappearance and death of family member, disruption of family by separation and divorce, dependent relative needing care at home, stressful life events affecting family and household, stress on family due to return of family member from military deployment, and alcoholism and drug addiction in family;
• Z64 — Problems related to certain psychosocial circumstances: Unwanted pregnancy, multiparity, and discord with counselors; and
• Z65 — Problems related to other psychosocial circumstances: Conviction in civil and criminal proceedings without imprisonment, imprisonment and other incarceration, release from prison, other legal circumstances, victim of crime and terrorism, and exposure to disaster, war, and other hostilities.

While the Z codes have been a welcome addition, some industry experts believe they can be expanded. “UnitedHealthcare wants to go further while honing 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 AHIMA, 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.”

Impact on Coders

More new codes will simply mean more education is in order, Fink-Samnick says. “Lifelong learning must be the mantra of every health care professional and organization, especially to ensure financial sustainability and long-term survival,” she notes. “More new codes will warrant ongoing education to coders, and especially the front-line professionals who regularly document on patients.”

Last year, the AHA advised organizations to engage in interprofessional education to get everyone up to speed. “I’ve long advised the creation of ‘coding coalitions’ of key players of interprofessional teams. The entire workforce must be up to speed on how to capture these new revenue streams,” Fink-Samnick says.

Bryant agrees, noting that ongoing education is always needed in the coding profession. “The coding professional and clinical documentation improvement professional should obtain complete and thorough education on social determinants. I could see physician queries being developed for this particular subject,” she says.

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.”