Social Determinants of Health

From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

January 16, 2020

From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic.

The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits.

Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

The full article can be downloaded below.  


Social Determinants of Health Among Adults with Diagnosed HIV Infection, 2017

January 16, 2020

Social Determinants of Health Among Adults with Diagnosed HIV Infection, 2017

HIV continues to disproportionately affect various populations in the United States. According to the 2017 HIV Surveillance Report, numbers and rates of annual diagnoses of HIV infection decreased from 2012 through 2016 in the United States [1]; however, numbers and rates increased in some populations and remained stable in others. Differences in HIV burden, by sex and race/ethnicity (i.e., blacks/African Americans, Hispanics/Latinos, and whites), have long been highlighted through HIV surveillance data in the United States. Factors other than individual attributes related to sex, race/ethnicity, or behavioral risk factors are likely contributing to the rate disparity, and may be partly explained through a better understanding of the social determinants that affect the health of populations.

The term social determinants of health (SDH) refers to the overlapping social structures and economic systems (e.g., social environment, physical environment, health services, and structural and societal factors) that are responsible for most health inequities [2]. Stratifying public health data by key SDH is useful in monitoring health inequities. Addressing the SDH that adversely affect health outcomes may advance efforts in reducing disparities in HIV diagnosis rates between populations. Addressing SDH also helps to quantify health differences between populations or geographic areas and can provide insight for identifying populations or areas that may benefit from HIV testing, prevention, and treatment initiatives.

The full CDC HIV Surveillance Supplemental Report can be viewed at this link.  


Want To Improve The Social Determinants Of Health? Here Are 8 Solutions

December 08, 2019

Want To Improve The Social Determinants Of Health? Here Are 8 Solutions

This wasn’t your typical discussion about social determinants of health. Today at Day 2 of this year’s Forbes Healthcare Summit in New York City, one of the sessions bore the title, “Four Solutions to Improving the Social Determinants of Health, Right Here, Right Now.”

Yes, that’s the word “solutions” in the title. Not “problems” or “99 problems” or “yeah, such is life.” Social determinants of health (SDOH) are the “conditions in the places where people live, learn, work, and play” that “affect a wide range of health risks and outcomes,” according to the Centers for Disease Control and Prevention (CDC). It’s been established over and over again that your environmental, social, job, and economic situations can greatly affect your health. In the words of Spandau Ballet, this much is true.

So, rather than waste any more words, let’s get to the solutions that the panel discussed:

Best Practices

  • Improve people’s diets and access to healthy food - Since diet can affect so many aspects of health, it’s not surprising that one of the solutions that emerged involved food. Another panelist, Jean C. Accius, Ph.D., Senior Vice President of AARP, emphasized that reducing food insecurity can have a “ripple effect,” because locations with food insecurity also have higher levels of diabetes and other chronic diseases.
  • Improve the physical environment such as increasing housing options, transportation options, and parks - Many of AARP efforts have focused on creating more “age-friendly communities.” We need to “think about how to create more livable communities.” That includes ensuring “greater housing options and greater transportation options.” 
  • Improve access to the Internet - These days, there’s much talk about the possibility of developing mobile and Internet-based approaches to improve the health of communities. Ah, but there’s one problem with that. Many people still don’t have reliable access to the Internet or have experience navigating the Internet.
  • Better understand the needs of individuals and bring care to them - All of the panelists agreed that healthcare needs to better understand the needs of patients. Not patients as one big glutinous mass, but as a range of different individuals. 
  • Integrate health care with retail - One panelist offered the possibility of “healthcare getting together with retail. Integrating retail more with the healthcare system.”
  • Develop and use technology to bridge the gaps in social determinants - Find ways to develop and use technology to overcome current gaps and disparities in SDOH. The other panelists talked about how technology can help better understand what consumers need and want.
  • Re-structure financial incentives to motivate addressing social determinants - The panel briefly discussed a seventh key solution: re-structuring financial incentives to further motivate the aforementioned solutions, a solution to help other solutions so to speak. “it is hard to get someone to do something when their salary depends on them not doing it.”
  • Changing the focus of healthcare in general - The emphasis of healthcare has to turn a completely new direction. There is an “urgent need for healthcare to better address social determinants, which is 80% of health. Too long has social determinants been relegated to the end of a meeting or conference."

The full Forbes article can be viewed at this link.  


As Healthcare Goes Digital, Social Care Lags Behind

December 07, 2019

As Healthcare Goes Digital, Social Care Lags Behind

Since 2009, federal legislation has awarded billions of dollars to physicians and hospitals that make health information technology part of their practice. While many highlighted the downsides of digitization, the providers who unlock its full potential know very well that it benefits clinical care immensely.

Most social care organizations, however, were left untouched by this outpouring of funds—not for lack of necessity, but their inability to qualify. Although their exclusion was no doubt a missed opportunity, digital tools and data solutions have emerged over the past decade that can more than make up for lost time.

The reasons for digitizing social care are as numerous as the challenges that come with it. Here are a few of each.

The full Forbes article can be viewed at this link.  


Webinar Presentation - Connecting Communities: HIEs and Social Determinants of Health

November 07, 2019

Slides and presentation from the 11.7.19 webinar

The vast majority of U.S. healthcare dollars and patient care efforts are currently spent on clinical factors and are not addressing the underlying socioeconomic and behavioral factors that greatly impact patient health. These forces, referred to as social determinants of health (SDOH), give providers and health plans meaningful insights into the health of their patient populations. SDOH data, which includes information on housing, income, crime, education, transportation, domestic circumstances, and food insecurity, allows stakeholders to proactively identify and treat those most at risk. SDOH improves both patient and population health by contributing to the complete picture of an individual, identifying populations that are most vulnerable, and facilitating connections with social services and programs that can improve their lives.

This webinar explores:

  • SDOH data sources and use across organizations
  • Center for Medicare & Medicaid Services (CMS) efforts regarding the use of SDOH
  • The role of health information exchanges (HIEs) with SDOH data, including challenges and solutions



Leonides (Lizzy) Feliciano, Vice President, Marketing, LexisNexis Health Care
Lizzy brings more than 20 years of HIT marketing experience to LexisNexis Risk Solutions. In her role she is responsible for creating strategies to grow the LexisNexis brand, drive thought leadership and establish innovation-centric messaging frameworks for a broad portfolio of data insights solutions. She has experience working with data, technology, and analytics organizations that deliver solutions impacting patient outcomes, data quality and interoperability. Lizzy holds a BA in Organizational Communication with a minor in Public Relations from Rollins College, and a MBA with a double concentration in Business Management and Marketing from the Crummer Graduate School of Business located in Winter Park, FL.


Chris Hobson, MD, Chief Medical Officer, Orion Health
Dr. Chris Hobson has global experience in the development implementation and adoption of Health Information Exchange, population health solutions, disease management programs, and innovative value-based models of healthcare delivery. He has over twenty years’ experience in North America, Europe, Middle East and the Asia Pacific region always working in the broad population health space. Prior to joining Orion Health, he developed integrated care strategic projects for a major health system, over three years, in Auckland New Zealand and worked in primary care and internal medicine as a physician for more than ten years. He has broad and deep experience across all areas of Health Information Exchange from business and clinical strategy through product design and development; sales and marketing; implementation, project management and evaluation of health IT projects. Most recently he has been working closely with LexisNexis on ways of integrating SDOH into Health Information Exchange for provider and payor focused HIEs.


Jordan Luke, M.A.Ec., Director, Program Alignment and Partner Engagement Group, CMS OMH
Jordan Luke is the Director of the Program Alignment and Partner Engagement Group (PAPEG) at the CMS Office of Minority Health (CMS OMH). PAPEG is responsible for working across CMS programs, policies, models, and demonstrations to ensure that the needs of vulnerable populations are met. He leads the CMS Equity Plan for Improving Quality in Medicare and the Minority Research Grant Program. PAPEG also provides Health Equity Technical Assistance to organizations interested in embedding equity into their policies, programs, and initiatives. Jordan gained cross-cultural experience from living and working abroad for fifteen years in Chile, Mexico, Bolivia, Canada, and the Navajo Nation. Jordan completed his M.A. in Economics from Boston University and B.A. in Psychology from Lee University. His passion for equity was ignited as an undergraduate student, where he led a student group called Deaf Outreach and founded an LGBT group to support sexual and gender minority students. Jordan is a native Spanish speaker and knows intermediate American Sign Language (ASL).

Webinar Presentation: Transforming Health with Social Determinants of Health Coding

October 10, 2019

Slides and recording from October 10, 2019 eHI webinar.

Using ICD-10-CM codes to capture social determinants of health (SDOH) data is an incredible opportunity to identify, document, and track factors impacting health, such as employment, food insecurity, and homelessness. This webinar featured the results of a recent collaboration between eHI and UnitedHealthcare, examining why ICD-10-CM codes are not being used to their full potential. As a result, the group developed a set of tools to promote the adoption and use of these codes by provider organizations and coding professionals.

Speakers from the collaboration will explain how to best use the tools, share what their organizations are doing to address SDOH, and answer questions such as:

  • What is the benefit of standardizing the capture of SDOH data?
  • What is a Z code for SDOH?
  • Can coding professionals use non-physician documentation to support ICD-10 CM coding for societal and environmental conditions?
  • Are there guidelines for using ICD-10 codes for SDOH?



Caraline Coats, MHSAVice President Bold Goal and Population Health Strategy, Humana
Caraline Coats is Vice President of Humana’s Bold Goal and Population Health Strategy, leading Humana’s mission to help improve the health of the communities it serves by making it easier for people to achieve their best health. Coats has been with Humana for over twelve years. She started as a Regional Director of Medicare Operations in Arizona and relocated to Florida, where she became the Vice President of Network Management and subsequently, the Regional Vice President of Network Management for the East Region. In her role before joining the Bold Goal team, Coats served   as Vice President of Humana’s Value-Based Strategies, leading the organizational advancement of innovative payment models that enable Humana to support providers as population health managers in value-based care relationships. Prior to Humana, Caraline was Vice President of Operations with a hospitalist company and Assistant Vice President of Managed Care for IASIS Healthcare in the Arizona and Nevada regions. She credits her understanding and experience working directly with physicians and hospitals for the opportunities she has had with Humana. Caraline holds an undergraduate degree in biology and a Masters in Health Services Administration from the University of Michigan. She and her husband have two sons, Michael (5 years old) and Nicholas (4 years old). Outside of Humana, Caraline spends her time with family and enjoys running.


Nelly Leon-Chisen, RHIADirector, Coding and Classification, American Hospital Association
Nelly Leon-Chisen, RHIA, is the Director of the Coding and Classification at the American Hospital Association where she is responsible for leading the Central Office on ICD-10-CM/PCS and HCPCS. The Central Office, in cooperation with the National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS) and the American Health Information Management Association (AHIMA), serves as the authoritative source on ICD-10-CM/PCS. She represents the AHA as one of the four Cooperating Parties responsible for the development of the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting. She is also the executive editor of the AHA Coding Clinic publications. She is the author of the ICD-10-CM and ICD-10-PCS Coding Handbook published by AHA Press. She has over 30 years of experience in the health information management field including consulting, teaching, technical and management experience in hospital health information management departments. She has lectured extensively on coding, DRG and data quality issues throughout the United States, Europe, Asia and Latin America. She is a Past President of the Chicago Area Health Information Management Association and a recipient of the Professional Achievement Award from the Illinois Health Information Management Association. 


Sheila ShapiroSenior Vice President, Strategic Community Partnerships, UnitedHealthcare
Sheila Shapiro joined UnitedHealthcare Community Plan of Arizona in 2009. Since joining the organization, she has held the positions Chief Operations Officer, Arizona Community and State, Plan President Washington Community &State, National Vice President of myConnections and National Vice President of Population Health and Clinical Innovation. Sheila has over 30 years of experience in the health care industry. In her current position as Senior Vice President, National Strategic Partnerships with United Healthcare, Sheila is responsible for the development, advancement and implementation of the industry-leading sustainable model to standardize and use non-traditional data elements and innovative strategic partnerships to improve health outcomes at scale. Prior to joining UnitedHealthcare, Shapiro held executive positions with Blue Cross Blue Shield of Montana, Molina and Premera Blue Cross. She has led a broad range of operations and strategic objectives including claims, customer service and financial operations. Shapiro earned a Master of Arts in management from the University of Phoenix, and her bachelor’s degree is from Arizona State University.  She also holds a financial management certificate from the Wharton School of Business.  Shapiro is an Arizona Women in Business honoree and has served as vice chair on the board of directors for the March of Dimes.  


Social Determinants of Health and ICD-10-CM Coding Resources


eHI Explains ICD-10-CM Coding for Social Determinants of Health

October 09, 2019

Download this information as 2-page document at the bottom of your screen.

  • What is an ICD-10-CM code?
    International Classification of Diseases, Tenth Revision, Clinical Modification coding, known as ICD-10-CM coding, is a system used by clinicians to classify and record all diagnoses and symptoms for care within the United States. Codes are based on the International Classification of Diseases, which is published by the World Health Organization (WHO), using unique alphanumeric codes to identify known diseases and other health problems. ICD-10-CM codes provide a level of detail that is necessary for storing and retrieving diagnostic information, compiling national mortality and morbidity statistics, and processing health insurance claims.


  • What is an ICD-10-CM Z code for Social Determinants of Health (SDOH)?
    ICD-10-CM codes include a category called Z codes, which are used to describe experiences, circumstances, or problems that affect patient health, but are not considered a specific disease or injury. Z codes identify patients facing socioeconomic and psychosocial circumstances that may influence their health status and contact with health services. Currently, codes included in categories Z55-Z65 document patients’ SDOH in a standardized manner.


  • How does standardizing the capture of SDOH data codes benefit population health?
    Traditionally, data recorded during a patient visit directly relates to a patient’s health but does not incorporate outside factors that can impact well-being. SDOH data captures information at a level traditional health data sources cannot, and ICD-10-CM Z codes can record this information, giving deeper insights into factors impacting health, such as employment, food insecurity, and housing. Standardizing SDOH would assist in identifying, documenting, and tracking additional markers of health, beyond the physical, and would permit clinicians, hospitals, and health plans to share the information through medical records and insurance claims data.


  • Are there guidelines for using ICD-10-CM codes for SDOH?
    ICD-10-CM diagnosis codes have been adopted under the Health Insurance Portability and Accountability Act (HIPAA) for all healthcare settings. Guidelines for Z codes are included in the Centers for Medicare & Medicaid Services (CMS) ICD-10-CM Official Guidelines for Coding and Reporting for FY 2020.


  • Why should providers, non-physician healthcare providers, and coders use ICD-10-CM Z codes for SDOH?
    Utilizing Z codes for SDOH enables hospitals and health systems to better track patient needs and identify solutions to improve the health of their communities. The extraction of SDOH data from the Electronic Health Record (EHR) for clinical, operational, and research purposes can facilitate tracking, identification, and referrals to social and governmental services. Rather than a new system or new tool to capture SDOH, leveraging existing ICD-10-CM codes offers an opportunity to expand on the existing system. This practical application brings SDOH into a clinician’s workflow and becomes a part of the patient’s electronic medical record and claims history.


  • What are the limitations of ICD-10-CM Z codes for SDOH?
    Currently, Z codes for SDOH capture some, but not all, domains of SDOH. Stakeholder groups have requested that the ICD-10 Coordination and Maintenance Committee expand the codes to represent more granular information that would inform more precise, effective, and efficient social interventions, such as “barrier situations” which prevent consumers from obtaining medications and routine and preventive care. Although coding for SDOH is not mandated, when there is documentation of SDOH in the patient’s notes, it is still possible to use Z codes in the same manner that medical coding is done. Coding professionals may not know to scan for SDOH or may be hesitant to use the codes. Additionally, if a code has not been developed for a specific SDOH issue, the issue will not be coded and will not be included in the patient’s overall plan of care, nor as part of the claim submission process, unless it is recorded as narrative text.


  • Are coding professionals allowed to use non-physician documentation to support ICD-10-CM coding for societal and environmental conditions?
    Yes, coding professionals at hospitals and health systems can report these codes based on documentation by all clinicians involved in the care of patients, such as case managers, discharge planners, social workers and nurses. In early 2018, the American Hospital Association’s (AHA) Coding Clinic published guidance that allows the reporting of SDOH ICD-10 codes based on non-physician documentation. The ICD-10-CM Cooperating Parties approved the advice, with the change effective February 2018.


  • Where can I find more resources and initiatives around SDOH data and ICD-10-CM Coding?


ICD-10-CM Coding for Social Determinants of Health

October 09, 2019

In Summer of 2019, eHealth Initiative and UnitedHealthcare’s National Strategic Partnerships Division convened a collaborative meeting of leaders from payer organizations and other stakeholder groups to address the use of ICD-10-CM codes for capturing social determinants of health (SDOH) data. This meeting marked a significant milestone in the shift to value-based care. Despite the competitive nature of healthcare, the private sector is working together to address factors pertinent to patient care and well-being in a sustainable, scalable manner. The group discussed the need for better education of provider and billing coders on the value of collecting and using SDOH data and identified strategies to accomplish this task:

  • Develop a consistent and unified approach to communicate and assist providers and coders in utilizing existing ICD-10-CM codes for SDOH.
  • Formulate a strategy and unified approach for providers and coders to assist with adoption and utilization of the proposed SDOH codes once approved.

Attendees agreed that the best strategy to communicate and promote the adoption of ICD-10-CM codes for SDOH to various stakeholder audiences was to:

  • Develop this document as well as two-page communication tools for various audiences, including providers and coders. The coder tool, Transforming health care: Why including SDOH codes on claims is critical and provider tool, Using SDOH coding to transform health outcomes are available for use.
  • Promote the use of the communication tools at various payer organizations through a high-level communication plan that outlines dissemination to stakeholder groups.

For a brief overview on the topic, check out our eHI Explains ICD-10-CM Coding for SDOH. Links to the provider and coder documents are forthcoming.

The Futures of eHealth: Social, Ethical, and Legal Challenges

August 04, 2019

The Futures of eHealth: Social, Ethical, and Legal Challenges

Looking into the futures of eHealth? The title of this publication might seem quite presumptuous at first. Its objective, however, is to serve a much more modest purpose, in that it strives to take a look at potential, likely, desired, anticipated or feared futures of digital health technologies and practices. When analysing the opportunities and risks associated with them as well as the social, legal and ethical challenges they might pose, what we also see in the process are the expectations and promises projected onto them.

eHealth or “digital health”, according to the World Health Organization’s European Office, “involves a broad group of activities that use electronic means to deliver health-related information, resources and services: it is the use of information and communication technologies for health” (World Health Organization 2017). As far as current developments and technological solutions are concerned, the WHO has further identified the following areas:

  • Electronic health records and interoperability of data;
  • Mobile health or mHealth;
  • Telehealth, where a patient can consult with a healthcare worker using Skype or even a regular telephone;
  • Wearable technologies (fitness trackers, medical devices, etc.) and
  • Technologies to support integrated care (WHO 2017).

Looking into the futures of anything always involves creating narratives. Rather unsurprisingly, the WHO’s definition characterises the role of technology use as entailing “strengthening health systems and health information systems” (World Health Organization 2017), a narrative of opportunity. These promises of eHealth are embedded in and reflective of much larger discourses that are often associated with (digital) technologies, which are mainly seen as a remedy to existing social problems. These discourses often centre around terms such as “empowerment”, “democratic potential”, “unifying cross-border force”, “special care for vulnerable groups” or “bridging distances”. And, indeed, there is an abundance of opportunities in digital health solutions that are directly associated with these technologies and practices.

The full paper can be downloaded below.  


More than just friends: in-home use and design recommendations for sensing socially assistive robots (SARs) by older adults with depression

July 01, 2019

More than just friends: in-home use and design recommendations for sensing socially assistive robots (SARs) by older adults with depression

As healthcare turns its focus to preventative community-based interventions, there is increasing interest in using in-home technology to support this goal. This study evaluates the design and use of socially assistive robots (SARs) and sensors as in-home therapeutic support for older adults with depression. The seal-like SAR Paro, along with onboard and wearable sensors, was placed in the homes of 10 older adults diagnosed with clinical depression for one month. Design workshops were conducted before and after the in-home implementation with participating older adults and clinical care staff members. Workshops showed older adults and clinicians saw several potential uses for robots and sensors to support in-home depression care. Long-term in-home use of the robot allowed researchers and participants to situate desired robot features in specific practices and experiences of daily life, and some user requests for functionality changed due to extended use. Sensor data showed that participants’ attitudes toward and intention to use the robot were strongly correlated with particular Circadian patterns (afternoon and evening) of robot use. Sensor data also showed that those without pets interacted with Paro significantly more than those with pets, and survey data showed they had more positive attitudes toward the SAR. Companionship, while a desired capability, emerged as insufficient to engage many older adults in long-term use of SARs in their home.

The full article can be downloaded below.