The Importance of Social Determinants of Health in Times of Crisis

As we have all been watching the healthcare and economic crisis unfolding before our eyes, I ponder how our industry can better help people now and set them up for success when the next healthcare epidemic or pandemic occurs.

Social determinants of health (SDOH) are an integral part of population health crisis management. SDOH are socioeconomic factors that are fundamental to a population's well-being and are critical determinants in population health. Healthy People 2020 describes social determinants of health as “conditions in the environments in which 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.” (Office of Disease Prevention and Health Promotion [ODPHP], 2020).

According to the ODPHP, 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” (2020).

Social determinants of health will help pinpoint the areas of greatest need for a population and 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 phrasing “patient” becomes limiting, with the terms of “person” or “individual” preferred.

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 merely a DRG (diagnosis related group), APC (ambulatory payment classification), E/M (evaluation and management) 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 person's physical, mental and social health is considered.

When one reviews the FY 2021 ICD-10-CM code and code descriptions in the Tabular List of Diseases, categories Z55-Z65, titled “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 (Holden, 2020)

Providing education and assistance and identifying the social determinants of health and the appropriate ICD-10-CM code assignment will help complete the puzzle on health status and provide 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.

The data 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 the American Hospital Association’s [AHA] 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 (2018, 1Q, p. 18). This makes sense because nurses spend most of the day with the patient, and case managers/social workers are focused directly on these social factors via their work scope.

The role that the CDI professional plays in the social determinants of health is that of a gatekeeper. 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 departments mentioned above 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 information technology (IT) support to ensure all 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. If social work and case management notes are hidden, this can be seen as a violation to the introduction of the FY 2021 ICD-10-CM 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” (Holden, 2020).

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. CDI's predominant goal is to assist in ensuring the documentation in the entire health record completely and precisely portrays the person’s health and wellness status. We must look at the person as a whole by considering socioeconomic factors in addition to medical factors.

The CDI professional’s role 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.