June 12, 2018

Assessing the Social Determinants of Health: The Secret Ingredient to the Cost, Coding, and Care

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Healthcare can incorporate SDoH data into daily workflows and operations.

Earlier in June I wrote about that necessary marriage of costs, coding, and the Social Determinants of Health (SDoH). I was proud to be a guest on ICD10monitor’s Talk-Ten-Tuesdays to continue this dialogue. The interest and response was powerful, and there was little surprise, given the strong industry attention on SDoH. However, through Talk-Ten-Tuesdays’ Q&A, another layer of the topic’s onion emerged: whether risk adjustment strategies to account for SDoH would be incorporated into the readmission equation. This is a vital theme that bears consideration and discussion.  

I’ve long said that any practitioners’ efforts are only as good as their assessments, independent of professional discipline and practice setting. Well, the same can be said about coding, for it is only as meaningful and accurate as the assessment and corresponding documentation allow for it to be. In the context of SDoH, achieving accurate assessment is challenging due to the very many moving parts. In fact, many experts would profess that SDoH have become among the most difficult topics to reconcile due to their vast reach over the domains of economic stability, education, neighborhoods and physical environment, food, community and social context, and the healthcare system. These areas yield concerning health outcomes across diagnostic groups and populations impacting mortality, morbidity, life expectancy, healthcare expenditures, health status, and functional limitations. As a result, those persons most predisposed to SDoH become part of an endless game of ping-pong, bouncing back and forth between the home and hospital. Making the vital interconnections among their care episodes and social needs bears directly on quality, care, and cost outcomes for the providers and practitioners involved.

Keen assessment and inclusion of accurate risk stratification of populations have yielded some opportunities to reduce costs while improving health and behavioral health outcomes. While the SDoH involve more than one single ingredient, using the myriad forms of data associated with them packs a flavorful punch. The identification and incorporation of this data into care practices and processes is a must. For those wondering if the health industry has the technology to assess and leverage this data properly, that would be a YES. Electronic health record systems are rapidly including SDoH data, with powerful results. This number has risen from 1.7 percent of products in 2012 to 25.2 percent today.

Managed care organizations already incorporate SDoH data into their processes. Predictive analytics and risk stratification tools are demonstrating their merit. Several health plans, including Gateway Health, have moved into serious action. Gateway serves approximately 600,000 Medicare and Medicaid managed care members across seven states (Pennsylvania, Delaware, West Virginia, Ohio, Kentucky, Arkansas, and North Carolina). SDoH data is used throughout the system to enhance patient engagement, with dramatic improvement, often producing 40 percent or higher engagement rates across conditions. This is a clear win, since 86 percent of current healthcare spending overall is related to chronic conditions, with the SDoH having an impact on 60 percent of outcomes.

The Center for Medicare & Medicaid Innovation State Innovation Models Initiative (CMMI-SIM) has been on the cutting edge of program development to enhance health and wellness for beneficiaries. Recognizing the strong impact of SDoH, CMMI-SIM funded the Accountable Health Communities model; the goal is to connect beneficiaries with the necessary community services to address health-related social needs. Thirty-two grants were awarded to entities in 2017, allowing participation in the model over a five-year period. Funds were secured to ensure the provision of navigation services to assist high-risk beneficiaries with accessing community services, as well as building strategic community partnerships to provide care. To date, more than $950 million has been awarded to involved states, linking their clinical, public health, and community-based resources: those geared to the SDoH.

The ICD-10 “Z” codes 55-65 are an important start, but could benefit from expansion. Just ask any front-line hospital social worker and/or case manager for recommendations of needed non-clinical additions, such as transportation. The industry has more evidence and validation than it knows what to do with toward proving the cost impact wrought by SDoH, with further validation released this month. Savings from $2,400 to over $2,600 per patient annually have been reported in populations directly linked with social service needs. Health organizations must incorporate case management models with professionals who are educated and trained in how to assess for the social and psychosocial factors that impact health (e.g. social workers, professional case managers, etc.). Linking patients across the transitions of care with appropriate non-clinical and social services, when possible, is a win toward achieving better health outcomes and financial incentives.  

Now, keep in mind one interesting tidbit. Despite the industry commitment toward using predictive analytics, the results are not all significant or favorable in the context of the integration of SDoH. A recent study demonstrated that adding SDoH data to more traditional clinical analytics did little to improve the accuracy
of predictive population health analysis. The outcomes were clear in that using professionals on the front lines who can assess for the SDoH was as, if not more, effective than reliance on the technology-driven data from electronic health records.

Back to that question posed on the June 5 Talk-Ten-Tuesdays broadcast: will risk adjustment strategies to account for the SDoH be incorporated into the readmission equation? The answer should be a resounding “yes!” Organizations can no longer afford for the non-clinical factors aligned with the SDoH to be ignored. The industry has the evidence, technology, and knowledge to assess and incorporate SDoH data into daily workflows and operations. In the end, assessment of the SDoH should be the primary ingredient of the coding, cost, and care “sauce,” as opposed to the best-kept secret. Like any other professionals, coders are only as effective in their efforts as the documentation allows for them to be.


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Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning industry expert who empowers healthcare’s transdisciplinary workforce through professional speaking, writing, mentoring, and consultation. Known as “The Ethical Compass of Professional Case Management,” Ellen is an esteemed author with more than 100 publications to her credit. She has developed content for many of the industry’s knowledge projects for case managers, including books, chapters, articles, and continuing education on the Ethical Use of Technology, Competency-based Case Management, Collaborative Care, the Social Determinants of Health, and dimensions of Workplace Bullying. Her contributions to professional case management, ethics, and clinical social work transverse professional associations and credentialing organizations.

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