Capturing SDOH: Set Your Revenue Cycle and Patient Population Up for Success

With attention on population health and quality initiatives, rev cycle leaders have turned their focus on how capturing SDOH impacts patients.

Social determinants of health (SDOH) are social factors, such as homelessness, illiteracy, a history of childhood trauma, and joblessness or underemployment, that can affect a person’s health.

With increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population. Experts have been urging hospitals to capture the codes for SDOH for years, but the message still doesn’t appear to be resonating.

Because of staffing shortages and financial losses as the result of COVID-19, revenue cycle leaders such as coding and CDI directors have been focusing their efforts elsewhere, especially since the capture of SDOH doesn't have an impact on reimbursement.

Adoption of SDOH capture is still only 1.59%, Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management, told the Revenue Cycle Advisor. The time is now for organizations to ensure that these codes are captured, she says.

The main reasons why hospitals aren’t capturing SDOH codes aren’t difficult to understand—there is no reimbursement for them, and their capture is not required, says Ferguson. Organizations also need to focus on medical diagnoses.

“Thus, [SDOH codes are] always going to fall to the bottom of the list or off the list,” she says.

But, as organizations start to place more of an emphasis on patient experience and population health, revenue cycle leaders have started baking in SDOH capture to improve patient outcomes.

Current electronic health record (EHR) systems may contribute to the lack of capture as these systems are often not automated for these codes, and the information is not always easy to find in the record.

A Florida health system found the same to be true and has started putting SDOH right into the EHR problem list, where doctors can see and act on them.

Jennifer Goldman, DO, chief of Memorial Primary Care at the six-hospital Memorial Healthcare System, based in Hollywood, Florida, recently explained to HealthLeaders how it embedded SDOH right into the EHR and how it uses that information to improve patient outcomes.

HealthLeaders: A JAMIA report from 2021 found there is no consensus on which SDOH measures should be captured in the EHR. How do you decide which ones to add?

Goldman: That's an ongoing discussion in our system. We utilize Epic, which has a social determinants of health wheel, which is just a graphic representation of the varieties of determinants of health that somebody is dealing with. And the major challenge for us in our organization was to determine which ones we were going to prioritize and start with.

We don't know if all of them truly impact health equally, but we do know that there are three that are a priority not only for us, but for Medicaid. If we can do something about these, we can probably impact more in a person's health than if we address resources elsewhere. Those are food, housing, and transportation. Substance abuse is a huge social determinant of health, but we already have a process for that, where we already screen everybody for that when they come in. The three social determinants of health we focus on are traditionally outside the wheelhouse of any physician. Those are things that we just did not ask people.

HL: How do you capture the data about the need, and how do you match the need with the actual service?

Goldman: We utilize the Epic release social determinants of health wheel. And we ask first our health coaches, our nurse navigators, and in some cases our social workers to review these determinants for the patients that were on their high-risk panel, patients that have significant ER visits or who are ill with multiple different chronic conditions.

We focused first on that population. Case managers were asking some of those questions anyway, but they were asking them in a non-capturable, non-standardized way. We standardized the way that we were capturing that data so that we could run analytics on it and show that information in the EHR to physicians. If our providers don't know that the patient they're treating right now is homeless or doesn't have access to healthy food or doesn't have access to transportation, that would probably impact their decision-making in terms of what treatment they were going to prescribe for that person.

We built something called an alert or a best practice advisory, where if somebody screened positive for homelessness, food insecurity, or transportation need, that would pop up [in front of] the clinician. And we took that a step further, because sometimes pop-ups in the EHR are negatively looked at. I never wanted to have an empty best practice advisory, where the doctor would have to do five more clicks to document that in the EHR. We drop the code for that specific social determinant of health into the problem list and into what we call a visit diagnosis.

We also included documentation that the patient was going to be automatically sent to our care team for follow-up in terms of how to access resources. We did that by having an automated in-basket so that it didn't hinge on a physician or a nurse practitioner or PA remembering to involve a social worker. This would happen automatically. We work with our community resources, such as the Broward County Task Force on Homelessness, and many other housing resources, as well as transportation assistance. With food, we work with multiple local food banks. We do direct connections with people we call and get those resources for them, instead of just handing a piece of paper to a patient.

HL: When did these processes go live, and what are the outcomes like so far?

Goldman: These alerts went live six months ago, and the outcomes have been significant. We've tripled the number of ICD-10 codes in the EHR for social determinants of health. That means that our physicians are documenting three times more on homelessness and food insecurity and transportation than they were previously. So we know that it's being captured.

We know that interventions are being done because we can track that as well. And we know that all those social determinants of health that we're screening for, all those patients ended up getting a referral to the care team and the care team contacted them and gave them the resources that they need. We're in the process of measuring outcomes, which ultimately is the most important thing. We're looking at data for no-show rates for appointments.