Tools to help track social determinants of health

There has been increased recognition of the impact of addressing social determinants of health.

How are you, as a physician, addressing social determinants of health (SDOH) when it comes to your patients? SDOH are factors that affect individuals' lives and health beyond the care that takes place in a physician's office. They are the conditions in which people are born, grow, live, work, and age and are responsible for health inequalities between populations.

The Office of Disease Prevention and Health Promotion, part of the U.S. Department of Health and Human Services, has established Healthy People 2030, which provides objectives for measuring public health and tools to track progress toward achieving them over the next decade. Healthy People 2030 focuses on five key domains: health care access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment.

Recently, there has been increased recognition in the policy and delivery communities surrounding the impact of these factors. CMS created the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool to inform patients' treatment plans and facilitate referrals to community services. The AHC HRSN Screening Tool has 10 questions in five categories that can be at least partially addressed by community services: living situation, food, transportation, utilities, and interpersonal safety. Each answer has a score, and if the numbers add up to 11 or more, then it is an indication that the person may need additional services to improve environmental factors affecting health or access to health care services.

Living Situation: The screening survey asks the patient what their current living situation is and allows them to identify if they have a steady place to live, worry about losing their space, or don't have a steady place to live, such as living in a shelter or outside on the street. It also allows the patient to identify any problems with their living, such as pests, mold, or water leaks.

Food: The patient can identify if they have been worried about not having enough food and having enough money to buy food.

Transportation: The survey asks if lack of reliable transportation has kept the patient from medical appointments, meetings, work, or getting things needed for daily living.

Utilities: The patient can indicate whether the electric, gas, oil, or water company has threatened to shut off services in their home.

Interpersonal Safety: The survey asks questions surrounding violence and abuse, such as if any family or friends have physically hurt, insulted, or threatened them.

The screening tool helps practices implement processes for talking to patients about these sensitive issues and to make community referrals. A growing number of screening tools have been developed and used for health care professionals to determine a patient's SDOH. One example is the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) Screening Tool, which is offered in over 25 languages to engage patients in assessing and addressing SDOH. The most common screening method is to give patients a paper intake survey in their native language, which allows them to check SDOH with which they have needed assistance recently. These include food, housing, transportation, employment, education, safety, and more, with the option to add other social needs or check no social needs. Another option is for practices to work with their electronic health records (EHRs) vendor to add these questions to the patient charts. However, while there have been improvements to many EHRs, this may not be possible in all systems.

ICD-10 Z codes are available to document SDOH data in EHRs. Any member of a person's care team can collect SDOH data through health risk assessments, screening tools, person-physician interaction, and individual self-reporting and later input them into the patient's EHR. Coders can assign the following SDOH Z codes based on the data collected. For an expansive list of ICD-10 Z codes, visit the website.

  • Z55: Problems related to education and literacy
  • Z56: Problems related to employment and unemployment
  • Z57: Occupational exposure to risk factors
  • Z58: Problems related to physical environment
  • Z59: Problems related to housing and economic circumstances
  • Z60: Problems related to social environment
  • Z62: Problems related to upbringing
  • Z63: Other problems related to primary support group, including family support
  • Z64: Problems related to certain psychosocial circumstances
  • Z65: Problems related to other psychosocial circumstances

Once SDOH are properly documented and coded in the EHR, the health care team can understand the social needs of the patient and develop or recommend resources to address them. There are a number of resources for patients and care teams to use to address SDOH:

  • The CDC offers programs that work across sectors such as housing, education, transportation, and in partnership with communities.
  • allows people to search and connect to support for financial assistance, food pantries, medical care, and other free or reduced-cost help.
  • offers resources to improve health and achieve Healthy People 2030 objectives.

Additional practical steps practices can take to manage SDOH are assessing internal bias and disparities and addressing any unconscious bias with intention. It is also vital for the practice workforce to reflect the populations they are serving by hiring a cohort that mirrors them. Patients find comfort in seeing people like themselves on their care team and speaking with someone who understands their language and culture, and that comfort level will result in better adherence and outcomes.

Advocacy for policies and payment models that prioritize primary care and equitable practices will ultimately improve patient and population health. For example, the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model (scheduled to start in January 2023) proposes to identify patients based on area-level need where social drivers may impact outcome and adjust the financial benchmarks accordingly. ACO REACH also will incentivize participating practices to build a team that addresses equity. Furthermore, ACP's Medical Practice and Quality Committee has worked throughout the pandemic to advocate for reforms that address the social drivers of health and improve access, payment, benefits, coding, documentation, and medical review. See ACP's recent policy paper, “Reforming Physician Payments to Achieve Greater Equity and Value in Health Care,” published June 21 by Annals of Internal Medicine.