Shoulder to shoulder with social determinants of health: Four policy/regulatory updates you may have missed

Keeping current on the massive amount of change in the social determinants space requires tenacity.  There are new codes released constantly, new mandates to comply with and an increase in accreditation and health equity ratings programs. There’s talk of assistance from artificial intelligence (AI), machine learning, coding automation, reporting analysis and chat bots for all the data. We should not forget however, this is about addressing social drivers of health – giving people what they need to attain their highest level of health. The focus remains on the patient, the fellow human. 

Where does this responsibility fall within the health care organization? Population health? Quality? Revenue cycle? Coding? Physician leadership? Nursing? Clinical documentation integrity (CDI)? Social work? Who should address the umbrella of care that is needed? The coordination of care starts when the patient presents – from a scheduled outpatient appointment to a high utilization emergency department (ED) visit because they have no alternative – and continues through the patient’s health care journey. Collection of data at each point is critical to the social determinants of health (SDoH) journey. Accurate and complete data is paramount to delivering patient care, population needs, utilization and outreach. 

The inequities in the SDoH domain are staggering. More than 50 percent of people experiencing homelessness in families are children under the age of 18. There is a direct correlation to these inequities and poor maternal health, infant death, incarceration and a multitude of poor societal outcomes. We are finally attaining the focus we need – from general awareness through government regulation. 

Capturing SDoH data begins with a designated range of ICD-10 codes, often referenced as Z codes, these are current “status” codes. The patient story is collected by hospital staff and then documented in the electronic health record (EHR). This EHR narrative is ultimately translated into codified data. This coded data is used to inform outcome-based care, community outreach and reporting. 

In order to help our clients prioritize the capture and coding of Z codes, we built a Z code foundation to optimize documents through computer-assisted coding (CAC) technology. We have developed SDoH content in hierarchical condition categories (HCC) management, CDI evidence sheets, CDI prioritization or in getting these codes into the top 25 on the final bill with advanced sequencing. We can build custom edits for coding staff to improve efficiency and ensure enhanced code capture.  

1. In addition, we work hard to make sure you’re up to date on the most recent government and accreditation guidance and requirements. Here are a few new updates from the Centers for Medicare & Medicaid Services (CMS): As this is such a dynamic space, we’re constantly taking action/awareness/amplification steps quickly.  
   1. In October 2022, CMS released new Z codes for transportation, material and financial insecurity. In April 2023, additional codes for literacy, physical environment, inadequate housing and personal history of abuse were released. For 2024, five new codes for conflicts in upbringing and group homes, as well as for a runaway, are being considered. 
   2. CMS is requesting comments on the agency’s health equity index which it seeks to introduce into Part D and Medicare Advantage Star Ratings. 
   3. Effective Aug. 1, 2023, CMS changed risk adjustment for Medicare Severity Diagnosis Related Groups (MS-DRGs) with inclusion and weighting of homelessness as a comorbidity/complication.This is a very important policy recognizing the impact of social needs on DRG weighting for three separate codes. Future expansion to new and revised homeless codes and an eventual reach into other health equity areas is likely. We can’t simply focus on housing insecurity and ignore the other domains of food, transportation, interpersonal safety and utilities. 
   4. In addition, under the CMS Hospital Inpatient Quality Reporting Program, hospitals will be mandated to report how many patients 18 years or older were screened (SDoH1), and the percentage of patients who screened positive for one of the drivers of health needs (SDoH2). While this is voluntary in 2023, it will be required beginning in 2024. Leveraging technology for clinical and coding insights that help connect documentation to accurately reported data is vital in determining the next steps to make a change and drive better patient outcomes in the SDoH space. 
2. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Beginning in July 2023, JCAHO made health equity “National Patient Safety Goal #16.” The goal is listed as "Improving health care equity for the hospital’s patients,” and it details five elements of performance which must be reported on. This is from an assessment of the health-related social needs (HRSNs) of an individual by developing a written health equity plan and shared as an annual updates with all stakeholders. 
3. The National Committee for Quality Assurance (NCQA) is also considering potential new HEDIS measures aimed at explicitly addressing SDoH. 

Once we have a patient who has determined social needs, can we stop there?  Must we not connect this person to resources? Who will manage the referrals – can burned out physicians handle more? Are organizations receiving these referrals correctly for the influx due to SDoH2? 

Here’s a real life example of how this will work: Downtown Hospital treats an underserved community in an urban setting. High cost ED visits are increasingly used for patients who have no other alternatives. Health needs are addressed, and basic patient education is provided along with discharge instructions. A mental health referral is needed, and a lengthy form completed for a Community Shelter. A separate referral is needed for Our Food Bank. Providers must complete patient documentation in the EHR and note their referrals in the system used for many downstream purposes, one being external reporting requirements. Our Food Bank is already stretched in terms of resources, and that need is increasing now that their ask has increased threefold. Community Shelter has a 60-day waiting list.   

Due to the increased focus on SDoH by hospital systems, government and communities, and the constant fluidity of regulatory and accreditation, one should expect marked changes to come. 

Michelle Badore, global clinical and nosology content manager at 3M Health Information Systems.