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Social Factors Influencing Health: Social Determinants and Social Drivers of Health and Health-Related Social Needs

Published on 

Wednesday, October 4, 2023

 | Coding 
 | Documentation 
 | Quality 

Social factors can have a positive and negative impact on our health and our general outlook on life. Hospitals have been tasked with assessing and identifying social factors that impact a patient’s health and well-being. Once identified, hospitals are taking action to mitigate the negative impact of social factors that are contributing to wide health disparities and inequities.

 

This article will review Social Determinants of Health (SDOH), Health Related Social Needs (HRSN), and Social Drivers of Health (SDOH).

 

Social Determinants of Health (SDOH)

 

HHS Health People 2030 National Health Initiative

The U.S. Department of Health and Human Services through their Healthy People 2030 national health initiative defines SDOH as being “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” They group SDOH into the five domains of economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.  

 

SDOH can negatively impact our health especially as we age. Collectively, the U.S. population is getting older, in fact “people aged 65 years and older made-up 17 percent of the population in 2020. By 2040, that number is expected to grow to 22 percent. An aging population means higher use of health care services and a greater need for family and professional caregivers.”

 

To learn more about how the Healthy People 2030 initiative is addressing SDOH and available resources, visit the initiative website at https://health.gov/healthypeople/priority-areas/social-determinants-health.

 

SDOH and ICD-10-CM Z Codes

ICD-10-CM Z codes are found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99). The SDOH codes are a subset of this chapter and range from Z55 – Z65 and are used to document SDOH data (i.e., housing, food insecurity, lack of transportation).

 

CMS recently published information about a new CMS infographic to help you understand and use Z codes to improve the quality and collection of health equity data in the September 14, 2023 edition of MLN Connects (https://www.cms.gov/training-education/medicare-learning-network/newsletter/2023-09-14-mlnc#_Toc145581413).

 

ICD-10-CM Official Guidelines for Coding and Reporting Documentation Tips Regarding SDOH Z Codes

  • 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 (i.e., Social Workers, Case Managers, or Nurses).
  • Patient self-reported documentation may be used when the information is signed-off by and incorporated into the medical record by either a clinician or provider.
  • SDOH codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, you would not use ICD-10-CM code Z60.2 (Problems related to living alone) without documentation of a risk or unmet needs for assistance at home.

     

    Z Codes IPPS FY 2024 Change in Severity Designation

    In the 2024 IPPS Final Rule, CMS recognized that homelessness is an indicator of increased resource utilization in the acute inpatient hospital setting. Therefore, they finalized the proposal to change the severity designation for three codes to a CC (comorbidity) for the purposes of MS-DRG assignment:

  • Z59.00: Homelessness, unspecified,
  • Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
  • Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule fact sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.”

Joint Commission Health-Related Social Needs (HRSN)

Effective January 1, 2023, the Joint Commission added a new standard to the Leadership (LD) chapter (LD.04.03.08: Reducing health care disparities for the hospital’s patients is a quality and safety priority). Within this standard are six new elements of performance (EPs) that were developed to address health care disparities as a quality and safety priority.

 

The Joint Commission noted in their June 20, 2022 R3 Report that “health-related social needs (HRSN) are frequently identified as root causes of disparities in health outcomes. We use the term HRSN instead of social determinants of health (SDOH) to emphasize that HRSNs are a proximate cause of poor health outcomes for individual patients as opposed to SDOH, which is a term better suited for describing populations. Understanding individual patients’ HRSNs can be critical for designing practical, patient-centered care plans.”

 

HRSNs address the Social Determinants of Health domain “Health Care Access and Quality.”

 

The EP 2 requirement tasks facilities with assessing a patient’s health-related social needs and providing information about community resources and support services. Examples they provide of a patients HRSNs includes:

  • Access to transportation,
  • Difficulty paying for prescriptions or medical bills,
  • Education and literacy,
  • Food insecurity, and
  • Housing insecurity.

     

    The Joint Commission summarizes the EP2 requirement by allowing hospitals the “flexibility to determine which patients to assess for HRSNs, which HRSNs to assess, and which resources to provide to address HRSNs.”  

     

    Hospital Inpatient Quality Reporting Measures: Social Drivers of Health (SDOH)

    In the 2023 IPPS Final Rule, CMS mandated that hospitals report two new measures as part of the Inpatient Quality Reporting (IQR) Program.

     

    SDOH-1: Screening for SDOH Measure

    This measure assesses whether a hospital implements screening for all patients ≥ 18YO at the time of admission for all five of the following health-related social needs (HRSNs):

  • Food insecurity,
  • Housing instability,
  • Transportation needs,
  • Utility difficulties, and
  • Interpersonal safety.

 

CMS defines HRSNs as “individual level adverse social conditions that negatively impact a person’s health or healthcare and that are significant risk factors associated with worse health outcomes as well as increased healthcare utilization.”

 

SDOH-2: Screen Positive Rate for SDOH Measure

This structural measure provides information on the percent of patients 18 years or older who were admitted for an inpatient hospital stay and screened for all five of the above HRSNs.

For both measures, voluntary reporting began with the CY 2023 reporting period and mandatory reporting will begin with the CY 2024 reporting period for FY 2026 (October 1, 2025 – September 30, 2026) payment determination and subsequent years.

 

In an SDOH FAQ documents, CMS clarifies that “at time of admission” to mean that “screening can occur any time during the hospital admission prior to discharge.” They also clarify that they do not require a specific tool to screen patients but do provide example tools.

 

Whether it is screening for social determinants of health, health-related social needs, or social drivers of health, once a need is identified, hospitals have the responsibility and opportunity to develop a patient centered care plan to address identified needs and connect the patient with resources in the community.  

 

Resources

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.