Understanding Provider Screening for Social Determinants of Health

May 15, 2019 - As healthcare professionals increasingly recognize the importance of the social determinants of health (SDOH) on patient outcomes and care, it will be important for them to create strategies for provider screening of these social factors.

The medical industry is inching itself closer to creating a holistic health experience, developing social supports and community health programs that target the downstream factors that influence a patient’s health.

But the success of these programs hinges on a provider’s ability to identify patients who would benefit from them. Without a sound provider screening process, efforts to address the SDOH will be for naught.

“A greater focus on social determinants of health can enable physicians to become stronger advocates for patients and to help reduce negative health outcomes that are often associated with social determinants of health,” said Jack Ende, MD, MACP, the president of the American College of Physicians in a recent call for better SDOH screening.

“Taking a closer look at social determinants of health can help us better understand and address the social factors that have an impact on patient health,” Ende added. “It’s important that physicians and other medical professionals recognize and account for social determinants of health to create a more comprehensive approach with our patients.”

Currently, there is no evidence base for SDOH screening. Instead, healthcare professionals across the country, in partnership with some key industry leaders, are testing different methods for detecting and flagging patients who may benefit from social supports.

Using the EHR, natural language processing

One study out of Massachusetts General Hospital (MGH) looked at natural language processing (NLP) and its ability to detect keywords indicating a social need.

The researchers deployed NLP on unstructured data – where most SDOH information would be located – in the EHRs of 132 adult patients. The program scanned for 22 SDOH keywords that could indicate that the patient experienced some sort of social need.

Specifically, the tool scanned records for the following terms: anxiety, depressed, sad, angry, neuro-vegetative, schizoaffective, substance, abuse, addict, AA, sober, cocaine, heroin, crack, mushrooms, prison, jail, homeless, shelter, stamps, stolen, and tox.

The tool found a mean of 14.1 of these terms for Medicaid patients, and six of these words for patients not enrolled in Medicaid. While this indicates that Medicaid patients are more likely than others to experience SDOH, it more so suggests that NLP could successfully identify these patients.

“Our novel approach offers the ability to use a patient’s EHR as a way to identify important psychosocial risk factors potentially driving or contributing to health care utilization and costs, and medical outcomes, among patients enrolled in Medicaid,” the research team stated.

“This study provides an important step forward for population health management by outlining a new method for identifying the important role that social determinants and mental health play in health outcomes, and offers a promising new approach to stratifying this risk burden on a population level.”

Developing patient intake surveying

Other healthcare professionals are making headway through patient surveying.

Researchers from the Virginia Commonwealth University (VCU) Health System found that simply using a paper and pen during patient intake was a simple and effective strategy for identifying patients experiencing the SDOH, they reported in a recent study published in the Journal of the American Board of Family Medicine.

The researchers introduced the SDOH surveying tool in its emergency departments (EDs) as well as the VCU General Internal Medicine (GIM) inpatient services departments.

The survey, which was printed on a small card, allowed patients to check several SDOH with which they may have needed assistance in the pervious 30 days. Options included food, housing, utilities, transportation, day care, legal services, employment, education, substance abuse, safety, or domestic violence.

Patients also had the option to write in other social needs or to select no social needs. Cards were offered in both English and Spanish.

The surveying cards proved effective, the researchers found. Ninety-three percent of ED patients filled out the survey, while 76 percent of those in GIM facilities participated in the survey.

What’s more, these surveys revealed true social needs. Over 60 percent of patients reported at least one social need within the previous 30 days, with needs for food, transportation, or reliable housing access coming out as most common.

Employing clinical coding, ICD-10 to document SDOH

Documenting the SDOH may also become easier as a set of ICD-10 codes come to the market, allowing providers to make a clinical note and prescribe a solution when a patient experiences a social need.

Efforts from both the American Medical Association (AMA) and American Hospital Association (AHA) have resulted in promises for more ICD-10 codes that could indicate patient experience with the SDOH.

In June 2018, AHA clarified use of some of the few ICD-10 codes available for flagging SDOH. The codes – Z55 through Z56 – are a part of the ICD-10 code set but are not often used. This is likely because patient experiences with SDOH do not always come up in patient-provider communications. Instead, non-clinicians are most often made privy of these circumstances.

“As a result, most hospitals and health systems are unable to report these codes because societal and environmental conditions are routinely documented and addressed by non-physician providers, such as case managers, discharge planners, social workers and nurses,” the bulletin explains.

The June 2018 announcement asserted that non-clinicians may use these codes to document the SDOH, making it easier for clinicians themselves to flag patients who may benefit from a social service.

A separate deal between the AMA and UnitedHealthcare called for even more ICD-10 codes related to the SDOH to allow providers to flag patients.

“UnitedHealthcare and the AMA share a common goal of expanding the health care system’s perspective to consider the whole person—-not just medical care—-by placing as much emphasis on people’s social needs as on their clinical needs,” said Bill Hagan, the president of Clinical Services at UnitedHealthcare. “By working together to leverage data, technology and the incredible expertise of our network physicians, we can more effectively address the social factors that limit access to health care.”

ICD-10 codes relating to the SDOH would be entered into the medical record. From there, providers can SDOH flags and refer patients to certain community health services that would ideally address those social needs.

“The AMA is excited to work with UnitedHealthcare through the continuing efforts of our Integrated Health Model Initiative (IHMI) to foster collaboration around innovative data and technology-driven processes for incorporating social determinants of health into routine medical care,” said Tom Giannulli, Chief Medical Information Officer of AMA’s IHMI. “The collaboration reinforces the importance of social and environmental factors in patient care, and will shape IHMI’s efforts to support clinical decisions with useful and valid data to achieve broad improvements in health and greater health equity.”