Social Determinants of Health: how they affect primary care

Please note, this communication applies to

Anthem HealthKeepers Plus, Medallion and

Anthem HealthKeepers Plus,

Commonwealth Coordinated Care Plus

(Anthem CCC Plus) offered by

HealthKeepers, Inc.

Coding disclaimer

The information in this presentation does not guarantee reimbursement or

payment for services.

Coding guidance outlined within the content of this presentation is not

intended to replace official coding guidelines or professional coding

expertise.

Providers are required to ensure documentation supports all codes

submitted for conditions and services.

All questions regarding claim, billed and reimbursement should be directed

to Anthem HealthKeepers Plus Provider Services at 800-901-0020 or

Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus

(Anthem CCC Plus) Provider Services at 855-323-4687.

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The American Academy of Family Physicians (AAFP) has granted approval

of one continuing medical education (CME) unit.

The American Academy of Professional Coders (AAPC) has approved this

training for one continuing education unit (CEU).

On-demand events are 1.0 CME or 0.5 CME units.

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Agenda

Part one: What are social determinants of health (SDOH)?

Part two: Addressing SDOH in primary care

Part three: Partnering with providers to tackle SDOH

Part four: Resources to address SDOH

Part five: Documentation and coding SDOH

References

Part one: What are social determinants of health (SDOH)?

What are SDOH?

SDOH are:

• Conditions in which people are born, grow, live, work, and age.

• Circumstances shaped by distribution of money, power, and resources at

global, national, and local levels.

• Responsible for health inequities, which are avoidable differences in health

status seen within and between groups.

Five key SDOH areas

Factors that influence health and outcomes include:

Economic stability

EducationSocial andcommunity

context

Health and healthcare

Neighborhoodand built

environment

Employment

Food security

Housing stability

Poverty

Early childhood education and development

High school education/graduation

Enrollment in higher education

Language and literacy

Civic participation

Discrimination

Incarceration

Social integration

Access to health care

Access to primary care

Health literacy

Access to healthy food

Crime and violence

Environmental conditions

Quality of housing

https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C39-SDOH.pdf

Impact on health outcomes

Three factors account for 80% of health outcomes

Physical environment Clinical care Health behaviors Socioeconomic factors

Physical environment

Clinical care

Health behaviors

Socioeconomic factors

20%

10%

30%

40%

Addressing health equity in health practice

Healthy People 2030, the US Department of Health and Human Services’

national health objectives initiative, includes among goals to achieve health

equity:

• Eliminate health disparities, achieve health equity, and attain health

literacy to improve the health and well-being of all.

• Create social, physical, and economic environments that promote attaining

full potential for health and well-being for all.

• Engage leadership, key constituents, and the public across multiple

sectors to take action and design policies that improve the health and well -

being of all.

Tips to measure health equity in your

practice

10

The Institute for Healthcare Improvement describes the following tips to

measure health equity:

• Allocate organizational resources to support efforts to measure

inequalities.

• Collect relevant data on sociodemographic characteristics of individuals.

• Select health outcome(s) of interest to measure improvements in health

equity over time (some examples of health outcomes are mortality, self-

reported health and functional status, or life expectancy).

Tips to measure health equity in your

practice (cont.)

11

• Select demographic characteristics of interest to examine against your

health outcome of interest (e.g., race/ethnicity, socioeconomic status,

gender).

• Examine raw data in tabular and graphical form (compare different

subpopulations and examine changes over time).

• Calculate stratified measures of disparities for different health outcomes

and social indicators of interest (examine within group differences and this

would identify the particular populations that could benefit from a targeted

intervention).

More information at: http://www.ihi.org/communities/blogs/6-tips-for-

measuring-health-equity-at-your-organization.

Part two: addressing SDOH in primary care

Addressing SDOH in primary care

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What is your practice’s approach to SDOH?

What systems do you have in place to ensure SDOH are addressed at patient visits?

In what ways does your practice currently help address patients’ SDOH?

Whose responsibility is this?

How does your practice currently identify and document SDOH, if at all?

Ask Identify Act

Identifying SDOH

Does not have to be performed by

provider

• Patient

• RN/MA

• Social worker

• Therapist

Can be performed

• Online, via patient web portal

• Via telephone

• At check-in

• During office visit (in person)

Self-administered vs. in-person/phone

interview

• Patients may be more likely to disclose sensitive information when self-administered

Barriers to identifying SDOH: providers

15

Lack of standardized

SDOH screening tool

Company policy (unclear

expectations, no leadership support)

Staff issues (availability,

engagement)

Implicit bias (belief or attitude toward any social group)

Ability to follow up (ways to contact

patient)

Barriers to identifying SDOH: patient reluctance

16

• Social stigmas

• Pride/embarrassed

• Safety concerns

• Fear of law enforcement

• Unable to read/interpret

• Gender or sexuality issues

Capturing SDOH

17

• Distribute the SDOH screening tool when patient arrives

• Make education materials available in waiting areas and exam roomsReceptionist/medical assistant

• Ensure adequate resources and staffing to screen

• Communicate to each staff member his or her responsibilities

• Provide training to staffAdministrator

• Determine resources available in your community

• Facilitate referrals to community resources based on patient needs

• Case management and follow up between visits

Social workers and/or community health workers (if

available)

Addressing SDOH in primary care (cont.)

18

Screening tools

Accountable

Health

Communities

Screening Tool

• CMS developed

• 10-item screening tool to identify patient needs in five domains

(food security, housing, transportation, utility and safety).

• Designed to be short, accessible, consistent and inclusive

The PRAPARE Tool

• Set of national core measures

• Aligns with national initiatives prioritizing SDOH (Health People

2020)

• Emphasizes measures that are actionable

• Templates exist for eClinicalWorks, Epic, GE Centricity and

NextGen

Health Leads

• 10-item screening tool

• Updated language to foster meaningful/effective dialogue between

providers/patients around essential needs

• Fully translated questionnaire template to remove barriers for

Spanish-speaking patient populations

https://healthleadsusa.org/resources/the-health-leads-screening-toolkit

Telehealth to fill critical gaps

• Episodic care for low-acuity health conditions

• Medication adjustment therapy

• Follow up on laboratory results

• Chronic care management

• Decrease no show rates

• Remote access to specialists in rural areas

• Counseling services when there is a transportation barrier

• Virtual outreach with housing assistance or eligibility assistance

• Health education

Part three: Partnering with providers to tackle SDOH

SDOH initiatives

21

Nationwide

• PRAPARE

• Healthy Neighborhoods Healthy Families (HNHF)

State of Virginia

• VA Community Indicators Dashboard

• Office of Health Equity

• VA Health Opportunity Index (HOI)

PRAPARE

22

Protocol for Responding to and Assessing Patient’s Assets, Risks, and

Experiences (PRAPARE) provides an implementation and action toolkit that

is being used by providers nationwide to gather data that will allow them to

assess their patients social needs so they can take measures to address

them.

The tool asks social health questions ranging from demographic data and

housing status to social-emotional health and physical security.

PAPARE Implementation and Action toolkit can be accessed at National

Association of Community Health Centers (NACHC) website:

https://www.nachc.org

Healthy Neighborhoods Healthy Families (HNHF)

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HNHF is a Nationwide Children’s Hospital’s initiative. It partners with multiple

community partners to tackle five high-impact social determinants:

• Affordable housing

• Education

• Health and wellness

• Safe and accessible neighborhoods

• Workforce development

More information at: https://www.nationwidechildrens.org

Virginia Community Indicators Dashboard

24

United Way of South Hampton Roads in Virginia and its partners have

created a community indicators dashboard for Greater Hampton Roads.

The partnership is using the data to identify and begin to address health

disparities impacting their community. Data on the platform helps highlight a

range of issues, including gun violence, trauma, mental health, and opioid

treatment.

More information at: https://www.hcinnovationgroup.com/population-health-management/social-determinants-of-health/article/21129988/virginia-community-indicators-dashboard-helps-prioritize-population-health-efforts

Office of Health Equity

25

The Office of Health Equity (OHE) shares data, tools, research, and other

resources to help eliminate racial, ethnic, and socioeconomic disparities

experienced by veterans.

OHE’s work is guided by a Health Equity Action Plan developed by

the Health Equity Coalition. Resources are organized around products

related to: data, awareness, health outcomes, partnerships, and workforce

trainings.

More information at:

https://www.va.gov/HEALTHEQUITY/Social_Determinants_of_Health.asp

VA Health Opportunity Index (HOI)

The Virginia Department of Health’s Office of Minority Health and Health

Equity (VDH-OMHHE) has launched the VA Health Opportunity Index (HOI).

The Virginia HOI is an online mapping tool of community health influences

that allows advocates, citizens, and providers to view the many factors that

affect health across the Commonwealth.

The VA HOI, which was first developed in 2012 as part of the VA Health

Equity Report, provides a compromise measure of SDOH. It is a part of the

State’s continuing efforts to improve the health of all Virginians.

https://www.vdh.virginia.gov/health-equity/virginia-health-opportunity-index-hoi

SDOH and home health

Home health agencies have adopted SDOH and offer services like:

• In-home hazard assessment and mitigation.

• Transportation services to ease access.

• Improving access to healthy foods.

• Developing care plans, then following through on those plans to improve

patient outcomes.

SDOH and home health (cont.)

The role of home health in managing SDOH can be improved by:

• Encouraging home health providers and their staff to gather further data on

SDOH and create mechanisms to incorporate into EHRs.

• Creating processes to arrange transportation, meals, and other SDOH

services.

• Incorporating SDOH data into home health predictive analytic solutions.

• Enhancing interoperability between SDOH providers, home health

providers and other providers.

Partnering with providers to tackle SDOH

29

Refer to case management department:

• Case managers and care coordinators can help to find services and

resources to assist eligible members for chronic complexed conditions that

may involve SDOH.

Providers can use Aunt Bertha* to find resources for patients:

• Link to Aunt Bertha: https://company.auntbertha.com/about/.

• Direct members to community resource(s) and make referrals for them

whenever possible.

HEALTH

Part four: Resources to address SDOH

Resources to help address SDOH

Know your local health department’s city and county health departments.

Use resources in patient communities that can help address SDOH.

Collaborate with organizations to address SDOH and advance health equity.

Team based approach to SDOH

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Member

PCP

Caregiver/

family

Local social services

SpecialistsDME

Pharmacy

Rides/ transportation

Resources to help address SDOH

Resource locator:

Coordinating

entities

• 211 VA - This is a free service that can help locate resources:

www.211virginia.org

• VA Department of Health (VDH): https://www.vdh.virginia.gov/

• Aunt Bertha — Search for free or reduced cost services like medical

care, food, job training and more:

https://company.auntbertha.com/about/

Food insecurity • Feeding America – Find local food pantries and meal programs to help

fight against hunger: https://www.feedingamerica.org/find-your-local-

foodbank

• Supplemental Nutrition Assistance Program (SNAP) — This program

(formerly known as food stamps) provides food-related assistance to

families with incomes of up to 185% of the federal poverty level:

https://www.dss.virginia.gov/benefit/snap.cgi

Resources to help address SDOH (cont.)

Resource locator (cont.):

Housing • Department of Housing and Community Development (DHCD):

https://www.dhcd.virginia.gov/

Jobs • Department of Labor and Industry: Career assistance for job seekers,

employment services and programs designed to assist with employment:

https://www.virginia.gov/

• Virginia Workforce Connection: https://www.vawc.virginia.gov/

Child

care

• Child Care Assistance (CCA): This program is available to the children of

income-eligible parents who are absent for a portion of the day due to

employment or participation in academic: https://dss.virginia.gov

Resources to help address SDOH (cont.)

More support from your community:

• National Diabetes Prevention program: Call 800-CDC-INFO

(800-232-4636) for diabetes support.

• National Domestic Violence Hotline: Call 800-799-7233.

• Virginia Poison Control Center: Call 800-222-1222.

• Women, Infants, and Children (WIC) program: https://vdh.virginia.gov/wic

• Quit Now Virginia Tobacco Quitline: 800-Quit-Now (800-784-8669).

Identifying SDOH example

36

M. Smith (age 36) - female member

Member with a diagnosis of bipolar disorder, nonadherent with medications

and office visits due. She is a new mom with an infant and a two-year old at

home. She has been attending court hearings for late rent payments.

Ask

• Living situation –late payments, court hearings

• Transportation – no car, no driver’s license

• Safety

Identify

• Document SDOH in the medical record

• Refer member to case management program to assist with medical needs

Act

• Contact local legal aid regarding housing issues

• Educate member regarding behavioral health case management program services, WIC program and Aunt Bertha link

Identifying SDOH example (cont.)

37

E. Brown (age 29) - male member

Member with uncontrolled diabetes, obesity, cholesterol issues. Shift work

has complicated keeping PCP visits and picking up prescriptions; recently

out of work due to injury and now without income.

Ask

• Living situation – lives alone in the apartment (2nd floor) no elevator, difficulty navigating stairs due to recent injury (not yet applied for subsidized housing)

• Transportation – difficulty using public transportation due to injury

Identify

• Document SDOH in the medical record

• Refer member to case management program to assist with chronic conditions

• Member can contact member services for transportation

Act

• Legal aid information and referral/consultation regarding workers’ compensation

• Refer to weight management programs

• Transportation benefits for pharmacy visit/medication pick up

Part five: Documentation and coding for SDOH

SDOH ICD-10-CM coding

39

ICD-10-CM Guideline I.B.14:

• “For social determinants of health, such as information found in categories

Z55-Z65, Persons with potential health hazards related to socioeconomic

and psychosocial circumstances, code assignment may be based on

medical record documentation from clinicians involved in the care of the

patient who are not the patient’s provider since this information represents

social information, rather than medical diagnoses. Patient self-reported

documentation may also be used to assign codes for social

determinants of health, as long as the patient self-reported

information is signed-off by and incorporated into the health record

by either a clinician or provider.”

SDOH ICD-10-CM codes (examples)

40

These codes are found in Chapter 21 of the ICD-10-CM code set

They are acceptable to be billed just like any other diagnosis code

The medical record documentation should support all codes reported on the claim.

Economic stability

• Z59.4 – Lack of adequate food and safe drinking water

• Z59.5 –Extreme poverty

• Z59.6 – Low income

Education

• Z55.0 –Illiteracy and low level literacy

• Z55.1 –Schooling unavailable and unattainable

• Z55.2 – Failed school examinations

Social and community

context

• Z60.2 –Problems related to living alone

• Z62.21 – Child in welfare custody

• Z63.4 –Disappearance and death of family member

Health and healthcare

• Z75.3 –Unavailability and inaccessibility of health care facilities

• Z75.4 –Unavailability and inaccessibility of other helping agencies

Neighborhood and built

environment

• Z59.0 -Homelessness

• Z59.1 –Inadequate housing

• Z65.1 –Imprisonment and other incarceration

References

41

• American Journal of Preventative Medicine, County health rankings:

relationships between determinant factors and health outcomes (2016)

• American Academy of Family Physicians, The EveryONE Project,

Addressing Social Determinants of Health in Primary Care: Team-based

approach for Advancing Health Equity

• BMJ Quality and Safety in Health Care, Health and social services

expenditures: Associations with health outcomes (2011)

• CMS Center for Medicare and Medicaid Innovation (CMMI), Accountable

Health Communities (AHC) Health-Related Social Needs (HRSN)

Screening Tool (2018)

References (cont.)

42

• Health Leads, Social Needs Screening Toolkit (2018)

• Health Affairs, Standardizing Social Determinants of Health Assessments

(2019)

• Office of Disease Prevention and Health Promotion, HealthyPeople.gov,

Social Determinants of Health

• National Academy of Medicine, Social Determinants of Health 1010 for

Health Care: Five Plus Five (2017)

• Virginia Department of Health: https://vdh.virginia.gov/

Q&A

43

* Aunt Bertha is an independent company providing community resource services on behalf of HealthKeepers, Inc.

https://providers.anthem.com/vaHealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Commonwealth Coordinated Care Plus (CCC Plus) benefits to enrollees. AVAPEC-3114-21 August 2021