The Centers for Medicare & Medicaid Services (CMS) reimburses for an optional assessment of social determinants of health (SDOH). When the evaluation is conducted as part of the Medicare Annual Wellness Visit (AWV), the beneficiary will not be burdened by a cost-sharing obligation.
The new CPT code G0136 covers the time to carry out a standardized, evidence-based SDOH risk assessment. Beyond detecting SDOH barriers, CMS stresses the need to address them through follow-up and referral to appropriate services.
Participating in the two sides of SDOH – identifying and addressing – is part of a continuum of involvement that can significantly impact a patient’s self-efficacy and motivation toward achieving their health goals.
Based on a provider organization’s patient care and financial objectives, leaders and clinicians can establish an SDOH assessment and intervention program that fits their capabilities and capacity.
The value of identifying and addressing SDOH
Identifying and addressing health-related social risk factors has been shown to improve the following:
- Patient health outcomes
- Unnecessary cost and utilization
- Value-based care competency
- Provider and patient satisfaction and engagement
- Physician burnout
Research has demonstrated that failing to identify hidden SDOH can lead to misdiagnosis and inappropriate care plans. Most critically, no prescription, care plan, or clinical guidance will be as effective without better insight into the barriers that patients face.
Care managers can assist patients only if they understand their practical limitations.
An SDOH evaluation, such as an evidence-based health risk assessment, helps identify patient risk factors. CMS suggests asking about five core topics: housing, food insecurity, transportation, utilities, and safety.
Care teams that ask the right questions can tailor care plans and interventions. Armed with SDOH data, providers can decide how they’ll support patients with additional needs.
What level of SDOH can your organization engage?
Figure 1 shows the three SDOH, or health-related social needs, levels an organization may offer with assessment.
Level 1: The care team may assess patients with suspected or known social risks and provide information in the form of a list of community or government resources that the patient can pursue on their own.
Level 2: Clinicians may complement their assessment with a more active level of aid, facilitating direct referrals and outreach to community resources on the patient’s behalf.
Level 3: Lastly, the organization may choose to provide some level of direct assistance in the form of an in-clinic food pantry, gift cards for public transportation or ride-share services, or online healthy cooking or exercise classes.
Deciding what level of support the organization wants to provide across the continuum shown in Figure 2 is typically an iterative process.
However, implementing a Chronic Care Management program can provide ongoing, focused resources that help patients navigate resources and participate in their care plans.
Solving social barriers and achieving personalized goals coincide. This provides needed momentum and boosts the patient’s confidence.
Identifying SDOH
Before the team can address barriers to care, however, they must build rapport and engage patients thoughtfully. Evidence-based assessments are only helpful if patients are honest about the details of their situation.
In a recent webinar, ThoroughCare client Maya Bell, PharmD, MBA, Director of Clinical Services at PharmaClin, expressed how she approaches SDOH assessments as a clinical pharmacist embedded in a rural-based family medicine clinic in North Carolina.
Dr. Bell shared that it can take time to build rapport and trust when broaching the topic of non-medical areas that may affect a person’s health. However, she prioritizes a judgment-free zone and uses cultural competency skills to engage patients. She avoids assuming the cause of someone’s beliefs, opinions, or attitudes.
She established conversations about issues like food, housing, and transportation as a natural part of medical discussions, setting the tone for establishing mutual expectations.
Compassionate questioning and outlining specific ways the care team can help patients in reaching their health goals show that help is available beyond advice.
Embedding the SDOH assessment into clinical workflow
Clinical care teams having the confidence and competence to initiate SDOH conversations is the first critical step; however, adding the SDOH assessment to existing services can be challenging.
ThoroughCare makes this seamless by integrating a health risk assessment into a digital workflow for Annual Wellness Visits.
Assessment data undergirds effective care planning. Analytics inform decisions around addressing SDOH across patient populations. Health risk assessment data enlightens quality measurement, value-based care, and performance outcomes tracking.
Addressing SDOH
One of the most powerful ways to address patient health barriers is through care management.
Regular touchpoints offer the opportunity to establish an SDOH-informed care plan. Care managers can use motivational interviewing to create patient health goals and work collaboratively to remove personal and social risk barriers to progress.
ThoroughCare enables this by providing worklists and dashboards that focus a care manager’s efforts. Evidence-based, educational content, provided by Healthwise, can enhance patient health literacy, which is a common barrier.
The platform also enables coordinated community referrals, direct communication and follow-up, and outreach to enable patient advocacy.
ThoroughCare facilitates SDOH assessment
ThoroughCare’s seamless workflow, robust analytics, and integrated data enable care managers to partner with patients toward action, including:
- Utilize assessments to uncover health concerns and needed patient-specific interventions
- Create care plans addressing SDOH issues, such as transportation, food security, and more
- Leverage platform features like barriers and interventions to identify and resolve SDOH risks
- Offer educational support through various resources, including videos, handouts, and pictures
- Provide comprehensive educational assistance
