Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
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