clinical documentation improvement

Clinical Documentation Improvement and Social Determinants of Health

The Clinical Documentation Improvement (CDI) profession continues to evolve as its importance strengthens.  The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus.  As the healthcare focus now shifts to population health, the CDI professional should be prepared to include a focus on the Social Determinants of Health (SDOH) to their role. 

SDOH are socioeconomic factors that have been shown to be fundamental to the wellbeing of a population and are key determinants in population health.  The Centers for Disease Control and Prevention (CDC) describes social determinants of health as “conditions in the places where people live, learn, work, and play (that) affect a wide range of health risks and outcomes.”

When one reviews the Official Guidelines for Coding and Reporting (OGCR) categories Z55-Z65 that describe social determinants of health, topics are seen in:

  • problems related to education and literacy
  • problems related to employment and unemployment
  • problems related to housing and economic circumstances
  • problems related to social environment
  • problems related to upbringing, primary support group and family circumstances
  • problems related to psychosocial circumstances

The importance of addressing social determinants of health is highlighted in Healthy People 2020, where one of the four overarching goals is to “create social and physical environments that promote good health for all” (CDC 2019). 

As Population Health and SDOH become a community focus in healthcare, it is imperative that CDI views and speaks of the patient as a whole person, not simply a DRG (Diagnosis Related Group) or RAF (Risk Adjustment Factor).  With the continuum of care prominent in healthcare, the setting (hospital, office or home, for example) is transitioning to a secondary focus when physical, mental and social health of the person is considered.

Social determinants of health will assist in pinpointing the areas of greatest need for a population and can help move the individual from “doing the best they can with what they have” to the next level.  As we begin to view the patient as a whole person outside of the typical healthcare setting, the verbiage “patient” becomes limiting, with the verbiage “person” or “individual” preferred over the term “patient”. 

The role that CDI plays in the social determinants of health is that of a gatekeeper, but its importance in this role is vital to the individual and the future of population health.  With congruence among case management, social work, and nursing, collaboration on an SDOH initiative benefits who we serve – the person.  Providing educational sessions by collaboration with the aforementioned departments along with healthcare providers will ensure the appropriate questions are included on a template.  This is an essential step in the process.  It may also be necessary for the CDI professional to go one step further and work with Health Information Management (HIM) and IT support to ensure the various documents are available at discharge so the appropriate SDOH codes can be assigned based on documentation from those departments. 

Our view on the medical record must be widened when it pertains to social determinants of health because this documentation is most likely not found in provider documentation.  According to Coding Clinic® 1Q 2018 p. 18, Coding of social determinants of health using non-physician documentation, these codes describe social factors, not medical factors, and therefore, can be assigned using non-provider documentation from care clinicians.  This makes sense because nursing spends the majority of the time with the patient, and case management/social work is focused on these social factors by their scope of work. 

Providing education and assistance with the identification and appropriate ICD-10-CM code assignment of the social determinants of health will help complete the puzzle on health status along with providing statistical data on the effects of SDOH on illness.  The data that is collected by this team initiative is valuable to research organizations such as the CDC, as it continues to explore the effects of SDOH on disease and illness in its quest to improve outcomes.  

Social determinants of health are important indicators of an individual’s health status because they have been shown to be influencers in disease and illness.  The predominant goal of CDI is to assist in ensuring the documentation in the entire medical record completely and precisely portrays the person’s health status.  It is crucial that we begin to look at the person as a whole by considering socioeconomic factors in addition to medical factors.  The role of the CDI professional as gatekeeper of the medical record will continue to serve the individual as a whole being, with the promise of a complete, precise depiction of their health status, now and in the future. 

Respectfully,

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O

CDI Education & Compliance Manager

MedPartners

 

References

 

AHA. Coding Clinic® 1Q 2018, p 18. AHA Coding Clinic® for ICD-10-CM/PCS © 2019 by the American Hospital Association

 

CDC. 2019. Social determinants of health: Know what affects health. Retrieved from https://www.cdc.gov/socialdeterminants/index.htm

 

Division for Heart Disease and Stroke Prevention. CDC. Healthy People 2020. Retrieved from https://www.cdc.gov/dhdsp/hp2020.htm

Official Guidelines for Coding and Reporting. FY 2019. Retrieved from https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf

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