The Importance of Social Determinants of Health in Times of Crisis
As we have all been watching the healthcare and economic crisis that is unfolding before our eyes, I ponder on how our industry can better help people now, plus set them up for success when the next healthcare epidemic or pandemic occurs.
How Do Social Determinants of Health Benefit the Community?
Social determinants of health (SDOH) are an integral part of population health crisis management. 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.” (2018, p.1).
According to the CDC, 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” (2018, p.1).
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.”
Clinical Documentation Integrity Can Help
As population health and SDOH become a greater focus in healthcare, Clinical Documentation Integrity (CDI) can lead the way by identifying the patient as a whole person, not simply a DRG (Diagnosis Related Group), APC (Ambulatory Payment Classification), Evaluation & Management (E/M) level, or RAF (Risk Adjustment Factor). With the continuum of care prominent in healthcare, the setting, such as the hospital, office, long-term care facility, or home, is a secondary focus when the physical, mental and social health of the person is considered.
Coding and Reporting
When one reviews the Official Guidelines for Coding and Reporting (OGCR) categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, that describes social determinants of health, codes that are especially relevant to a healthcare crisis are seen in subcategories that describe:
- problems related to employment and unemployment
- problems related to housing and economic circumstances
- problems related to social environment
- problems related to psychosocial circumstances (Schmidt & Willard, 2020)
Providing education and assistance along with identification of the social determinants of health, and the appropriate ICD-10-CM code assignment will help complete the puzzle on health status along with providing statistical data on the effects of SDOH on the well-being of an individual. When SDOH codes are mapped geographically, a clear picture begins to emerge on the neighborhoods and regions that are most susceptible to the effects of disease outbreaks.
Data Collection Needed
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 identify risk and improve outcomes. Population health programs will greatly benefit from this data by its use in resource allocation so the right resources get to the right people at the right time.
Our view on the health record must be widened when it pertains to SDOH because this documentation is not typically found in provider documentation.
According to Coding Clinic®, 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 (American Hospital Association, 2018, 1Q, p. 18). This makes sense because nursing spends the majority of the day with the patient, and case management/social work is focused directly on these social factors via their scope of work.
The role that the CDI professional plays in the social determinants of health is that of a gatekeeper, and their importance in this role is vital to the individual and the future of population health during times of crisis. With congruence among case management, social work, nursing, and the provider, collaboration on a SDOH initiative benefits who we serve – the individual.
Providing education sessions through collaboration with the aforementioned departments will ensure the appropriate questions are asked. This is an essential step in the process.
It will likely be necessary for the CDI professional to go one step further and work with Health Information Management (HIM) and IT (Information Technology) support to ensure all of the pertinent documents are available at discharge for code assignment. This is especially true with the social work and case management notes, which are often not visible on final coding.
The coding professional cannot code what they cannot see in the record, and if social work and case management notes are hidden, this can be seen as a violation to the introduction of the FY 2020 Official Guidelines for Coding and Reporting where it states, “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated” (n.d., p.1).
Social determinants of health are important indicators of an individual and population health status because they have been shown to be influencers in disease, and a marker of well-being and adaptability.
The predominant goal of CDI is to assist in ensuring the documentation in the entire health record completely and precisely portrays the person’s health and wellness status. It is critical that we 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 health record will continue to serve the individual as a whole being, with the promise of a complete, precise depiction of their social determinants of health status which can be used in identification of at-risk areas and appropriate population health resource allocation, now and in the future.
There is no time like the present to take yesterday’s lessons and plan for tomorrow.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O
Clinical Documentation Integrity Content Manager
AMN Healthcare Revenue Cycle Solutions (RCS)
American Hospital Association. (2018, 1Q). Patient self-reported information and social determinants of
health codes. Coding Clinic®.
Centers for Disease Control and Prevention. (2018, January 29). Social determinants of health: Know
what affects health. https://www.cdc.gov/socialdeterminants/index.htm
Division for Heart Disease and Stroke Prevention. (2014, March 13). Healthy People 2020. The Centers
for Disease Control and Prevention. https://www.cdc.gov/dhdsp/hp2020.htm
National Center for Health Statistics. (n.d.). ICD-10-CM Official guidelines for coding and reporting FY
- Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf
Newhouser, K. (2019, June). Clinical Documentation Improvement and Social Determinants of Health.
MedPartners. Social media article.
Schmidt, A. & Willard, P. (Eds.). (2020). ICD-10-CM expert for hospitals: The complete official code set.