Social determinants of health

Addressing social determinants of

health in primary care

Agenda

2

I. Introduction to social determinants of health (SDOH)

II. Addressing SDOH in primary care

III. HealthKeepers, Inc. partnering with providers to tackle SDOH impacting

Anthem HealthKeepers Plus members

IV. Team-based approach to SDOH — includes information about

Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus

(Anthem CCC Plus) Provider Services

V. Documentation and Coding for SDOH

VI. Next steps

3

Introduction to SDOH

Part one

Introduction to SDOH

4

• Environmental conditions that affect a wide range of health, functioning

and quality-of-life outcomes including risks.

Born

Live

Learn

PlayWork

Worship

Age

Introduction to SDOH (cont.)

5

• Factors that influence health and outcomes include:

Economic

stabilityEducation

Social/

community

context

Health/health

care

Neighborhood

environment

Employment

Food insecurity

Housing instability

Poverty

Early childhood

education and

development

Enrollment in

higher education

High school

Graduation

Language and

literacy

Civic participation

Discrimination

Incarceration

Social cohesion

Access to health

care

Access to primary

care

Health literacy

Access to foods

that support

healthy eating

patterns

Crime and

violence

Environmental

conditions

Quality of housing

Introduction to SDOH (cont.)

6

• Impact on health outcomes:

Medical care

SDOH

80%

20%

Sources: NASM/American Journal of Preventative Medicine/BMJ Quality and Safety in Health Care

7

Addressing SDOH in primary care

Part two

Addressing SDOH in primary care

8

• Ask these questions in your practice:

How does your practice currently identify and document SDOH, if

at all?

Whose responsibility is this?

In what ways does your practice currently help address patients’

SDOH?

What systems do you have in place to ensure SDOH are addressed at patient visits?

Addressing SDOH in primary care (cont.)

9

• Implement SDOH screening in your practice:

Ask

Identify

Act

Addressing SDOH in primary care (cont.)

10

• Opportunities to engage patients:

Patient checks in.

Height and weight checked in

hallway.

Patient sits in waiting room.

Remaining vital signs checked in

exam room.

Patient meets with clinician.

Patient meets with counselor.

Patient stops at billing/scheduling

station.

Patient leaves.

Display posters in the waiting room that prompt patients to discuss their social

needs.

Nurse/medical assistant (MA) confirms social needs with patient and provides

information to office clerk to cross reference needs with available community

resources.

Distribute SDOH screening tool at check in to be completed in the waiting room.

Display posters in exam room that prompt patients to discuss their social needs.

Clinician discusses social needs with patient, shares available resources

and works to develop a plan to address patient’s SDOH.

Nurse or MA finalizes plan to address SDOH and provides referrals to community

resources.

Office staff schedules follow-up appointment; patient receives additional lists of

available county resources.

Addressing SDOH in primary care

https://healthleadsusa.org/resources/the-health-leads-screening-toolkit11

• Screening tools:

Accountable

Health

Communities

Screening Tool

• CMS developed

• 10-item screening tool to identify patient needs in five domains

(food security, housing, transportation, utility and safety).

• Designed to be short, accessible, consistent and inclusive

The PRAPARE

Tool

• Set of national core measures

• Aligns with national initiatives prioritizing SDOH (Health People

2020)

• Emphasizes measures that are actionable

• Templates exist for eClinicalWorks, Epic, GE Centricity and

NextGen

Health Leads

• 10-item screening tool

• Updated language to foster meaningful/effective dialogue between

providers/patients around essential needs

• Fully translated questionnaire template to remove barriers for

Spanish-speaking patient populations

[

12

Partnering with providers to tackle SDOH

Part three

Partnering with providers to tackle SDOH

13

• Core health-related social needs screening questions:

Housing instabilityFood

insecurity

Transportation needs

Utility needs

Interpersonal safety

Partnering with providers to tackle SDOH (cont.)

14

• Social needs screening tool:

Partnering with providers to tackle SDOH (cont.)

15

• Refer to case management department.

° Case managers and care coordinators can help to find services

and resources to assist members.

• Provider can use Aunt Bertha to find resources for patients.

° Link to Aunt Bertha: https://agpassociate.auntbertha.com.

° Direct member to community resource(s) and make referrals for

them whenever possible.

COMMUNITY

HEALTH

RESOURCES

16

Team based approach to SDOH

Part three

Team based approach to SDOH

Department of Social Services: https://www.dss.virginia.gov/localagency/index.cgi.17

Winchester/Northern region

Central region

Charlottesville region

Roanoke/Alleghany region

Far Southwest region

Halifax/Lynchburg region

Tidewater region

Team based approach to SDOH (cont.)

18

Coordinating

entities

Virginia 2-1-1: An easy-to-remember phone number connecting people with free information on available community

services. When you dial 211, a trained professional listens to your situation and suggests sources of help using one of

the largest databases of health and human. services in Virginia

VA Navigator (Senior Navigator, Veteran Navigator): 501c3 non-profit organization that provides free information

about health, aging, disability and postmilitary resources available to Virginians. The information focuses on issues

such as health, financial concerns, legal questions, health facilities, housing options, transportation, exercise

programs, advocacy and more.

Department of Social Services: Energy Assistance, food assistance, temporary cash assistance, Farmers Market

listings, medical assistance, https://www.dss.virginia.gov/localagency/index.cgi

Aunt Bertha: Search for free or reduced cost services like medical care, food, job training and more.

Food

insecurity

Feedmore: Central Virginia Food Bank, FeedMore (Hunger Helpline) at 1-804-521-2500. Hunger Hotline is the food

referral program for people in search of food. This resource is listed in our Aunt Bertha Community Resource Link as

well.

Housing

State Rental Assistance Program (SRAP): The Department of Behavioral Health and Developmental Services

(DBHDS) created the SRAP to serve individuals with developmental disabilities in the Settlement Agreement population

who want to live independently in their own housing.

Homeless Crisis Line: Call 1-804-972-0813 if you are homeless or will lose housing within a few days.

JobsVirginia Employment Commission: Virginia Employment Commission offers career assistance for job seekers,

employment services for veterans and programs designed to assist with employment www.vec.virgina.gov

1-866-832-2363.

Child careChild Care Subsidy Program: The Child Care Subsidy Program provides financial assistance to eligible families to

help pay for the cost of child care so they can work or attend education or training programs.

Behavioral

health

Community Services Board: The mission of the Virginia Association of Community Services Boards is to achieve a

publicly funded system of quality public and private services in Virginia that is ultimately responsive to individuals

with behavioral health and developmental disability service needs, and their families https://vacsb.org/csb-bha-

directory.

Team based approach to SDOH (cont.)

19

• Aunt Bertha resource locator — Contact your provider rep for a Demo!

Team based approach to SDOH (cont.)

20

Call National Customer Care (NCC) line — Medallion

members: 1-800-901-0020

Anthem CCC Plus Provider Services

1-855-323-4687

Medallion members:

Directed to case management for referral

Anthem CCC Plus members:

Directed to care coordinator or other specialist for referral.

Call case management

1-844-533-1994

Associate will identify reason for referral and follow up with

member.

If member is agreeable, care coordinator

or case manager will complete

assessment to assist member and provide

resources.

Team based approach to SDOH (cont.)

21

Member

PCP

Caregiver/

family

Local social services

SpecialistsDME

Pharmacy

Transportation

Example: M. Smith (36 year-old) female member

22

• Bipolar, noncompliant with medications and office visits due to SDOH; new

mom with infant/two-year old at home; attending court hearings for late

rent payments.

•Living situation — Late rental payment, court proceeding being pursued for eviction

•Food — Not enough food may eat meals only one or two per day.

•Transportation — No transportation, no driver’s license, reluctant to use public transportation with [two] small children (no child care to attend appointments).

•Utilities

•Safety

Ask: (Screening questions)

•Member may be referred to health plan and case management program to assist with coordination of medical needs. Social worker consultation for community resource needs.

•Document SDOH in the encounter record.

•Contact local Department of Social Services (DSS) to determine programs available/ CommonHelp-Virginia DSS online application for assistance.

Identify:

•Contact local DSS to determine programs available/CommonHelp-Virginia DSS online application for assistance for fuel assistance and other programs.

•Contact local legal aid regarding housing issues.

•Educate member regarding behavioral health case management program services for possible referral involving behavioral health needs.

•Educate member regarding community resources for local community services boards (behavioral health needs).

•Ensure member is linked with maternal/child resources such as Women, Infants, and Children (WIC), SNAP (formerly food stamps), child care assistance programs, and Childcare Aware.

•Educate member regarding Aunt Bertha Community Resource Link.

•Provide referral information for Housing Crisis Hotline.

Act:

Example: E. Brown (29 year-old) male member

23

• Uncontrolled diabetes; obesity, with cholesterol issues. Shift work has

complicated keeping PCP visits and picking up prescriptions; recently out

of work due to injury and now without income.

•Living situation — Lives alone in second floor apartment without elevator. Difficulty navigating stairs due to recent injury (not yet applied for subsidized housing).

•Food — Lives in food desert without access to fresh, healthy food.•Transportation — Recent difficulty using public fixed-route transportation due to disability.• Utilities — Requires utility bill assistance to maintain electricity.•Safety.

Ask: (Screening questions)

•Member may be referred to health plan and case management program for RN case management interventions to address chronic health conditions. Social worker consultation for community resource needs.

•Aunt Bertha Community Resource Link for information regarding SDOH needs.

•Contact local DSS to determine programs available/CommonHelp-Virginia DSS online application for assistance.

•Value-added benefits for weight management.

•Member Services for in-network providers and transportation.

Identify:

•Contact local DSS to determine programs available/CommonHelp-Virginia DSS online application for assistance.

•Aunt Bertha Community Resource Link for SDOH needs such as healthy foods, financial assistance, housing, utility/fuel assistance.

•Value-added benefits for weight management such as Active Fit or Weight Watchers.

•Legal aid information and referral/consultation regarding workers’ compensation.

•Member Services will identify in-network providers with extended practice hours.

•Transportation benefits for pharmacy visit/medication pick up.

•Value-added benefit for grocery store, farmer’s market and/or food pantry visits.

•Educate member regarding Human Arc for Best Benefits program and assistance with Social Security disability application.

•Healthwise offers education involving chronic conditions.

Act:

24

Documentation and coding of SDOH

Part five

Documentation and coding for SDOH

25

Helpful tips:

• Document the screening questions and results in each medical

record encounter.

• Embed SDOH assessments in the electronic medical record

systems.

• Set triggers to ensure questions are not left blank.

• Have members complete questionnaire while waiting to be seen,

then discuss the responses during the encounter.

• Allow the member to divulge as much information as they care to

share.

• Use ICD-10-CM diagnosis codes to report health risks related to

SDOH.Tip: We can also use this information to assist members and target outreach to support different areas!

Documentation and coding for SDOH (cont.)

26

Z55: Problems related to education and literacy

Z56: Problems w/ employment

Z57: Occupationalexposure to risk factors

Z59: Problems w/housing and economics

Z60: Problems related to social environment

Z62: Problems related to upbringing

Z63: Other problems

Z64: Problems related to certain psychosocial

Z65: Problems related to other psychosocial

• These codes are found in Chapter 21 of the ICD-10-CM code set.

• They are acceptable to be billed just like any other diagnosis code.

• Codes from this chapter can be assigned based on documentation

from clinicians other than the diagnosing provider.

• The medical record documentation should support all codes reported

on the claim.

Documentation and coding for SDOH (cont.)

27

Social determinant ICD-10-CM code/description

Difficult/unstable

housing or housing

support services

instability

• Z59.0 Lack of housing or

• Z59.1 Inadequate housing or

• Z59.8 Other problems related to housing and economic

circumstances

Environmentally-

compromised housing

(for example, lead)

• Z77.1 Contact with and (suspected) exposure to other

environmental pollution

Food insecurity • Z59.4 Lack of adequate food and safe drinking water

Transportation difficulty • 791.89 Other specified personal risk factors, no elsewhere

classified

Interpersonal violence • Z91.41 Personal history of adult abuse

Economic difficulties • Z59.9 Problem related to housing and economic

circumstances, unspecified

Lack of social support • Z60.4 Social isolation, exclusion, and rejection

How you can help — next steps

28

Implement/maintain a team-based approach to addressing SDOH.

Assess opportunities where your staff/resources/workflows could

better address SDOH.

Leverage SDOH screening tools.

Accountable Health Communities Screening Tool

Familiarize team with local health department and statewide

resources that address SDOH.

Establish/maintain workflows for referring patients to SDOH

resources in the community/case management.

How you can help — next steps (cont.)

29

• Refer members to case management or care coordination.

• Guide members to the Aunt Bertha website.

• Tell members to contact the customer care line to learn about value-added

benefits including transportation, GED assistance, Books for Babies, air

purifiers or meal assistance after a hospital stay!

References

30

• Office of Disease Prevention and Health Promotion, HealthyPeople.gov,

Social Determinants of Health

• National Academy of Medicine, Social Determinants of Health 1010 for

Health Care: Five Plus Five (2017)

• American Journal of Preventative Medicine, County health rankings:

relationships between determinant factors and health outcomes (2016)

• BMJ Quality and Safety in Health Care, Health and social services

expenditures: Associations with health outcomes (2011)

• American Academy of Family Physicians, The EveryONE Project,

Addressing Social Determinants of Health in Primary Care:

Team-based Approach for Advancing Health Equity

References (cont.)

31

• Health Leads, Social Needs Screening Toolkit (2018)

• Health Affairs, Standardizing Social Determinants of Health

Assessments (2019)

• Centers for Medicare & Medicaid Services (CMS) Center for Medicare and

Medicaid Innovation (CMMI), Accountable Health Communities (AHC)

Health-Related Social Needs (HRSN) Screening Tool (2018)

https://mediproviders.anthem.com/vaHealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance

Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical

Assistance Services to provide Commonwealth Coordinated Care Plus (CCC Plus) benefits to enrollees.

AVAPEC-2326-19 March 2020