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About Us Addressing Health Disparities and SDOH

Addressing Health Disparities and SDOH

Social determinants of health

What are social determinants of health?

Understanding social determinants of health will allow physicians to make a difference in the lives of their patients.

Social determinants of health (SDOH) are conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.1, 2 Many SDOH significantly impact health, including the mental health of patients, and can have long term effects that contribute to the increased prevalence of chronic disease. The National Academy of Medicine found that medical care only accounted for 10-20% of an individual’s health outcomes, while SDOH are 80-90% of contributing factors.3

Examples of SDOH include:

  • Health Care System: health coverage; provider availability; provider linguistic and cultural competency; quality of care
  • Economic Stability: employment; income and expenses; debt
  • Physical Environment: housing; transportation; safety; parks and playgrounds; zip code geography
  • Education: literacy; language; early childhood education; higher education
  • Food: hunger; access to health options
  • Community and Social Relationships: social integration; social systems; community engagement; discrimination; stress

1 “Social Determinants of Health,” World Health Organization, accessed May 18, 2021,
https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.

2 “Social Determinants of Health: Know What Affects Health,” Centers for Disease Control and Prevention, accessed, May 18, 2021, https://www.cdc.gov/socialdeterminants/index.htm.

3 Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine 50(2):129-135. https://doi.org/10.1016/j.amepre.2015.08.024.


Providing guidance

Osteopathic philosophy and SDOH

As a trusted source of health information and guidance it is important that osteopathic physicians partner with patients and families to address their immediate and long-term needs including the risk and protective factors that affect their quality of life. It is essential to address problems as they are identified and work with the practice team to refer to community-based resources.

Osteopathic physicians:

  • Focus on understanding the patient as a complete individual including body, mind, and spirit.
  • Believe there is more to good health than the absence of pain or disease and provide a holistic and comprehensive approach to treating patients.
  • Support each patient in achieving a high level of wellness by focusing on physical and behavioral health and the individual’s environment.

Assessments and referrals

Incorporating SDOH assessment and referral system

Below are key issues to consider with incorporating SDOH assessment and a referral system in your practice:

  • Work with the practice team on adopting a “whole-person” approach.
  • Educate staff on the importance of screening for and documenting patients’ SDOH needs.
  • Identify SDOH assessment tools and resources appropriate for your practice.
  • Collaborate with the practice team on developing an effective workflow system.
  • Obtain training for the practice team on identifying SDOH risk and protective factors and effective referral to community resources.
  • Document any SDOH needs by utilizing the established SDOH ICD-10 Z codes.

Crucial partnerships

Making a difference for your patients during difficult times

The COVID-19 pandemic has significantly changed the lives of families in the US and worldwide. Families are experiencing the social, economic, and health effects of the pandemic. Stressors including poverty and food insecurity, loss of employment, isolation, changes in childcare and school systems, risk of infection, complications following infection, and loss of family members due to the pandemic will continue to have long-term effects on your patients and their families.

The immediate and long-term impacts of the pandemic have not been evenly distributed and stressors have increased for individuals already struggling with low-wage work and meeting their family needs from paycheck to paycheck. The pandemic also disproportionately affected racial and ethnic minority groups considering the inequities in the rate of poverty, health care access, and other socioeconomic factors. These stressors can contribute to a toxic environment and can lead to mental health problems, family violence, and substance use, further affecting quality of life.

Osteopathic physicians partnering with families on their immediate and long-term needs during these difficult times is crucial. As a trusted health care provider, you can make a difference now more than ever in the lives of your patients and their families.


SDOH Assessment

Patient Assessment of Individual, Family, and Community Needs

Below is an example questionnaire physicians can distribute to patients:

These questions are to assist the physician in understanding better what might be affecting your health and well-being. Obtaining this information will help us to work together with you to develop a plan that fits your life. We also may be able to assist you with connecting to resources in the community. Some of these questions may be sensitive, the information you provide is confidential and used to partner with you on your overall health and well-being.

Please circle your answer:

  • What is your current employment status? (Retired, Disabled, Not Employed, Employed Part Time, Employed Full Time)
  • Do you ever eat less than you feel you should because there was not enough money for food? (Yes, No)
  • Do you sometimes need to see a doctor, but are not able to because of cost? (Yes, No)
  • Have you ever had to go without health care because you did not have a way to get there? (Yes, No)
  • Are you able to afford your medications? (Yes, No)
  • Do you ever need help reading medical materials? (Yes, No)
  • Do you have stable housing? (Yes, No)
  • Are you often worried about having enough money for your bills (gas, electric, water)? (Yes, No)
  • Do you feel safe at home? (Yes, No)
  • Is there something that you would like to share with the physician that is cultural or spiritual in nature? (Yes, No)
  • Does your spirituality impact the health decisions you make? (Yes, No)
  • Are you concerned about discrimination today based on your sexual orientation, race, or ethnicity? (Yes, No)
  • If you have children, do problems getting child care make it difficult to work or study? (Yes, No)
  • Do you often feel sad and depressed? (Yes, No)

Please include anything you would like to discuss with the physician today.

Thank you for completing these questions. Your overall health is important to us!


Coding correctly

Coding for SDOH services

In January 2021, several changes were made to the descriptions of the outpatient Evaluation and Management (E&M) codes. Level of service can now be determined by either total time spent on patient care on the calendar day of service, or by the level of Medical Decision Making (MDM). Diagnosis or treatment limited by Social Determinants of Health (SDOH) is an element in either the Moderate (99204 / 99214) or the High (99205 / 99215) levels of MDM.

Documentation of SDOH elements in the medical record increase the correct level of coding and should be considered carefully. The Z-codes are not presently included in many electronic medical record systems for explicit entry, but the appropriate documentation should be entered in the chart and the level of billing adjusted accordingly.

Examples of patient experiences related to SDOH:

  • Patient returns to the office today having missed the last two scheduled appointments due to difficulties with transportation. Patient has been out of medications for several weeks and has presented to a local Emergency Department at least once for associated symptoms.
  • Patient has recently been evaluated by Orthopedics for bilateral knee pain. Found with severe tricompartmental degenerative disease and total knee replacements were advised. Scheduling of this is delayed due to patient’s morbid obesity and continued daily tobacco use.
  • Patient was prescribed additional anti-hypertensive agents on last visit. However, was unable to afford them and has continued taking prior medications. Blood pressure has been very high when checked at the local fire station.

Established SDOH ICD-10 Z codes

Use of these codes can potentially increase payment to the practice for patient care.

Z55 – Problems related to education and literacy

Illiteracy/low-level, schooling availability, failing school, underachievement, discord with teachers.

Z56 – Problems related to employment/unemployment

Changing of job, losing job, no job, stressful work schedule, discord with boss/co-workers, bad working conditions.

Z57 – Occupational exposure to risk factors

Noise, radiation, dust, other air contaminants, tobacco, toxic agents in industry, extreme temperatures, vibration, others.

Z59 – Problems related to housing and economic circumstances

Homeless, inadequate housing, discord with neighbors/landlord, problems with residential living, lack of adequate food/safe drinking water, extreme poverty, low income, insufficient social insurance/welfare support.

Z60 – Problems related to social environment

Adjustment to life-cycle transitions, living alone, cultural differences, social exclusion and rejection, discrimination/persecution.

Z62 – Problems related to upbringing

Inadequate parental supervision/control, parental overprotection, upbringing away from parents, child in custody, institutional upbringing (orphan or group home), hostility towards child, inappropriate/excessive parental pressure, child abuse including history of (physical and/or sexual), neglect, forced labor, child-parent conflict.

Z63 – Other problems related to primary support group, including family circumstances

Spousal conflict, in-law conflict, absence of family member (death, divorce, deployment), dependent relative needing care, family alcoholism/drug addiction, isolated family.

Z64 – Problems related to certain psychosocial circumstances

Unwanted pregnancy, multiparity, discord with counselors.

Z65 – Problems related to other psychosocial circumstances

Civil/criminal convictions, incarceration, problems after release from prison, victim of crime, exposure to disaster/war, religious persecution.


Resources

Health Disparities Resources

Agency for Healthcare Research and Quality

2019 National Healthcare Quality and Disparities Report – Shows the progress and opportunities for improving healthcare quality and reducing healthcare disparities. Chartbooks on specific topics, such as access to care, patient safety, and healthy living, provide more detailed information. In addition, downloadable slides are available for presentations.

Priority Populations – Information regarding the delivery of healthcare to low-income individuals, minority groups, women, children, the elderly, and individuals with special health care needs.

AHRQ Data Highlight Inequities Related to COVID-19 Hospitalizations and How Vaccination Prioritization May Effect Equity

National Institutes of Health

The National Institute on Minority Health and Health Disparities (NIMHD) is one of the 27 Institutes and Centers of the National Institutes of Health (NIH), the nation’s premiere medical research agency. NIMHD’s work touches the lives of millions of Americans burdened by disparities in health status and health care delivery, including racial and ethnic minority groups, rural populations, populations with low socioeconomic status, and other population groups.

National Institute of Minority Health and Health Disparities

The State of Health Disparities in the United States

Centers for Disease Control and Prevention

CDC Health Disparities Topics – Information on populations identified to be at-risk for health disparities. Includes lists of COVID-19 Articles on Health Equity and COVID-19 Webinars on Health Equity.

National Center for Health Statistics

Health Equity Considerations and Racial and Ethnic Minority Groups

Health Equity: Promoting Fair Access to Health

Office of Minority Health – Think Cultural Health

This website features information, continuing education opportunities, resources, and more for health and health care professionals to learn about culturally and linguistically appropriate services, or CLAS. Launched in 2004, Think Cultural Health is sponsored by the Office of Minority Health.

Advancing Health Equity at Every Point of Contact

National Academy of Medicine

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Substance Abuse and Mental Health Administration

Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the US

Additional Publications

How to Help Someone with Anxiety or Depression During COVID-19

Hospitalization and Mortality among Black Patients and White Patients with COVID-19


SDOH Resources

Centers for Disease Control and Prevention - Social Determinations of Health (SDOH) website

This website provides CDC resources for SDOH data, research, tools for action, programs, and policy. They may be used by people in public health, community organizations, research organizations, and health care systems to assess SDOH and improve community well-being. Information and tools available on this website were generated or funded by CDC within the last 10 years.

Social Determinants of Health: Know What Affects Health

Healthy People 2030 - SDOH

One of Healthy People 2030’s 5 overarching goals is specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” In line with this goal, Healthy People 2030 features many objectives related to SDOH. These objectives highlight the importance of “upstream” factors — usually unrelated to health care delivery — in improving health and reducing health disparities.

Social Determinants of Health – Healthy People 2030

Healthy People 2020 - SDOH

The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways to create social and physical environments that promote good health for all. This website also shows Healthy People 2020 data on SDOH.

Social Determinants of Health – Healthy People 2020

Rural Health Information Hub

Provides evidence-based models and resources to address social determinants of health in rural communities from the Rural Health Information Hub.

Social Determinants of Health in Rural Communities


Screening tools for SDOH

Additional resources regarding social determinants of health

National Association of Community Health Centers

The tool includes 15 core questions and 5 supplemental questions. The data can be directly uploaded into many electronic health records as structured data. It is generally administered by clinical or nonclinical staff at the time of the visit, but a paper version can be given to the patient to self-administer.

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences tool

The Centers for Medicare & Medicaid Services Accountable Health Communities

A 10-question screening tool from the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) is meant to be self-administered.

Health-Related Social Needs Screening Tool (AHC-HRSN) (innovation.cms.gov)

Addressing Food Insecurity: A Toolkit for Physicians

Toolkit providing guidance on incorporating the food screening process into practice workflow, choosing the right tool, and intervening to help address food insecurity.

Addressing Food Insecurity: A Toolkit for Physicians

Strengths-Based Approaches to Screening Families for Health-Related Social Needs

Document providing recommendations to guide strengths-based screening for health-related social needs.

Strengths-Based Approaches to Screening Families for Health-Related Social Needs

What are ACEs and how do they relate to toxic stress?

This infographic explains how to reduce the effects of ACEs and Toxic stress that affect people at all income and social levels.

What are ACEs and how do they relate to toxic stress?

Screening for Adverse Childhood Experiences and Trauma

This technical assistance tool offers various approaches and considerations for screening adults and children for ACEs and trauma.

Screening for Adverse Childhood Experiences and Trauma

Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care

This report includes effective strategies primary care providers can implement to improve the health and resiliency of individuals with histories of trauma.

Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care

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