By Jennifer Polello

Last year may have marked the beginning of social determinants of health (SDoH) finally receiving the attention they deserve for their considerable influence on health outcomes. Both payers and providers made strides in initiatives incorporating SDoH information into care and treatment plans, recognizing the major role that factors like housing, transportation and food security play in patients' long-term health. In 2020, progress should continue along similar lines, with more investment in projects to help meet the socioeconomic and environmental needs of patients and community members.

Given the impact of SDoH, many healthcare organizations (HCOs) have prioritized establishing partnerships with community organizations to address these issues. However, SDoH can vary considerably between communities. Understanding local resource needs requires capturing and analyzing SDoH data, which can be a challenge for many HCOs.

As a not-for-profit, provider-owned health plan, Community Health Plan of Washington (CHPW) had experienced frustrations around the limited availability of accurate SDoH data which is critical to understanding and improving health outcomes. The CHPW network includes 20 community health centers (CHCs) that operate more than 130 clinics across the state, about 2,500 primary care providers, 14,000 specialists, and upwards of 100 hospitals. In an effort to better understand its members’ SDoH, address the homelessness crisis prevalent in its community and improve overall health outcomes, CHPW’s leadership launched an initiative to systematically address SDoH challenges across its network.

Better documentation of SDoH by using Z-codes (IDC-10-CM codes)
To effectively understand these challenges, CHPW wanted to leverage a shared analytics platform to assess SDoH issues and track the efficacy of resource allocation and interventions. This meant that we needed to ensure our provider network consistently captured structured SDoH information by logging the information on either a claim or in the electronic health record (EHR), where it would be accessible to our analytics platform.

Essential to this effort were IDC-10-CM Code Categories (often called “Z-codes”) that can be used to capture SDoH. Categories range from education (Z55) to neighborhood and the built environment (Z57) to social and community context (Z60, Z62, Z63, Z65). Because these codes are part of the broader IDC-10 system and could be easily entered on claims, we felt that they were the best way for our network to document SDoH data.

One other benefit of using Z-codes is that the IDC-10-CM official guidelines state providers can assign social determinant codes in ICD-10-CM based on documentation from any member of the care team, including non-physicians like social workers, case managers, nurses, and other allied staff. Since CHCs use care team models, this flexibility in the guidelines makes it easier for providers and support staff to document SDoH information.

To engage CHCs, CHPW first surveyed each organization about their current practices for collecting and managing SDoH data. We asked whether they were collecting any data, how they were collecting and documenting this information, and whether they were currently using the information to coordinate community services. Additionally, we asked about the assessment tools they were using to capture data from patients.

How to improve SDoH data capture
The results of our survey revealed that only 20% of the CHCs routinely collected SDoH data on all patients. To increase the consistency and quality of data capture, we knew that we needed to implement a comprehensive training program with supporting tools and follow-up coaching.

First, we provided broader context for providers and staff about the impact of SDoH and the five critical benefits of data capture:

• Developing effective interventions to address SDoH barriers
• Program identification and improved access to care for patients
• Population health trend identification and monitoring
• Payment reform incentives for approaching health holistically and in an integrated fashion
• Panel management that recognizes providers serving complex patients

Next, we provided detailed training on ICD-10 Z-codes, along with guidance working with care team members other than the provider. We recognize that providers already have substantial workloads and documentation burdens, and wherever possible we want to work with our provider network to alleviate those burnout risks. Our trainers and clinical data integration team covers workflow design in our training program when working directly with the clinics.

We also stressed the importance of capturing Z-codes within the EHR so that documentation can be recognized by our plan. While each CHC has a different EHR instance, we discussed best practices that would be broadly applicable.

More comprehensive data leads to more resources to address homelessness
CHPW has now engaged leaders at many of our CHCs and is using executive roundtable discussions to shape our SDoH strategy with input from our provider network. Enabled by our investment in a population health management platform from Arcadia, we have broad plans to use our SDoH data to shape our approach to community-based partnerships, population health assessments, risk stratification, and patient identification for programs, as well as risk adjustment.

As a network, we decided to prioritize data capture around a major crisis facing Washington state: homelessness. Our population health economics team undertook an analysis that showed the state of Washington’s Medicaid authority that homelessness was a major issue for our members. Our team examined claims and other self-reported health risk data to conclude 17,908 or (7.1%) of members are potentially homeless or face housing insecurity.

The data we collect will help us receive additional funding to support our members, while also making it possible for our teams to better manage members’ health outcomes and address housing insecurity. As a result of implementing this analytics platform, we now receive premium payments from the state to help our members address their health needs to provide whole-person care.

Through CPHW’s analytics investment with Arcadia, we have been able to administer an innovative pay-for-performance program, drive value-based payments, run a strong risk documentation program and support quality improvement initiatives across the network. With improved SDoH documentation, we can now provide more resources for our provider network to address the social and health needs of our most vulnerable populations. It all starts with an organized community effort to initiate and implement key changes to our healthcare system, like capturing the right data, to address SDoH and improve long-term health for all people.

About the author: Jennifer Polello is a health care professional with expertise in chronic disease management and clinical care coordination programs and services. Professional experience includes public health policy and administration, finance, quality improvement, clinical decision support, health information technology and clinical transformation. She is currently serving as the Senior Director of Quality and Clinical Transformation at Community Health Plan of Washington which serves 20 federally qualified community health centers across the state of Washington.