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Social Determinants of Health | Care Management

SDOH and Care Management: Engaging, Assessing, and Addressing

May 7th, 2024 | 7 min. read

Kathryn Anderton, BSN, RN, BC-RN, CCM

Kathryn Anderton, BSN, RN, BC-RN, CCM

Director of Clinical Services, ThoroughCare

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ThoroughCare's clinical team recently hosted a webinar, “The Impacts of Social Determinants of Health (SDOH) on Patient Care and Outcomes.”  They were joined by Dr. Maya Bell, PharmD, MBA, Director of Clinical Services at PharmaClin.

As a clinical pharmacist embedded in a rural-based, family medicine clinic in North Carolina, Dr. Bell provided real-world insight into the value of approaching SDOH issues. She also gave recommendations for creating a compassionate and practical approach.

Why SDOH is critical to patient health outcomes

Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. They include the conditions in which people are born, grow, work, live, and age, as well as the broader set of forces and systems shaping daily life. 

According to the Centers for Medicare & Medicaid Services (CMS), providers across 32 Accountable Health Communities will screen seven million beneficiaries using the Health-Related Social Needs (HRSN) Screening Tool. This is projected to happen in the next five years. 

CMS states, “Growing evidence shows that if we deal with unmet HRSNs like homelessness, hunger, and exposure to violence, we can help undo their harm to health. Just like with clinical assessment tools, providers can use the results from the HRSN Screening Tool to inform patients’ treatment plans and make referrals to community services.”

Care management is well-positioned to identify and help overcome SDOH barriers

Care management programs – like Chronic Care Management, Behavioral Health Integration, and Transitional Care Management – are ideally positioned within provider and payor organizations to engage patients, screen for SDOH needs, and provide resources to overcome barriers to care.

Recognizing and addressing SDOH is becoming a standard part of delivering patient-centered care that achieves three goals:

  • Improves health equity
  • Enhances patient outcomes
  • Promotes a more holistic approach to well-being

During ThoroughCare’s live webinar with Dr. Bell, the following poll question highlighted the SDOH issues attendees see regularly. 

Which of the following issues do you see your patients struggling with most? 

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CMS reimbursement for SDOH screening and care management

In response to the need to identify SDOH factors, CMS established the standalone code G0136 for administering a standardized, evidence-based Social Determinants of Health Risk Assessment. 

Certified clinical personnel can bill for this once every six months. When the SDOH risk assessment under code G0136 is conducted within the Annual Wellness Visit, Medicare will pay 100% of the allowance with no beneficiary cost-sharing. 

CMS allows SDOH screening at the time of the initial or subsequent wellness visits. However, the Final Rule doesn't mention the Welcome to Medicare Visit, which may indicate that G0136 is not covered during that event.

In addition to coverage for SDOH screening, Medicare care management programs provide reimbursable time that can be used to:

  • Coordinate care and resources
  • Remove barriers to care
  • Support patients with goal-setting, referrals, and self-management 

With CMS support for screening and care management services, payor and provider organizations can remove SDOH barriers by:

  • Engaging patients and providers around SDOH
  • Collecting SDOH data
  • Assessing SDOH barriers to care
  • Addressing SDOH needs 

Engaging patients and providers around SDOH

Dr. Bell shared that it can take time to build rapport and trust when first broaching the topic of non-medical areas that may affect a person’s health. When she first came on board at her clinic, talking about issues like food, housing, and transportation from the initial conversation helped to set the tone and establish mutual expectations. 

She also works to ensure that patients feel heard and that the care team is aware of their needs. This approach helps meet the patient’s needs and improves their satisfaction with the practice and their physician. 

It’s her priority to create a judgment-free zone where she doesn’t assume the cause of someone’s thoughts, opinions, or attitudes. Cultural competence and training that equip teams for this type of personal and sensitive conversation make this possible.

The power of building cultural competence with the care team and office staff heightens awareness that can lead to improved patient care through:

  • Holistic patient assessment
  • Tailored treatment plans
  • Early intervention and prevention
  • Improved patient-provider communication
  • Enhanced patient engagement
  • Reduced health disparities
  • Improved chronic disease management
  • Efficient resource allocation
  • Community collaboration
  • Promotion of health equity

Engaging patients around social determinants through cultural competence entails creating, or enhancing, each healthcare organization’s policies and systems, as well as each professional’s set of behaviors, attitudes, and beliefs.

As systems and individuals grow in their cultural self-assessment, provider organizations will better manage the dynamics of differences among patients.  Care teams will adapt to and support diverse cultural contexts. Providers will achieve significant health equity by addressing individual needs and removing barriers at the policy and procedure level.

Collecting SDOH data

Personal patient information forms the core of SDOH information. It is critical to understanding the individual context of where a person lives, works, and ages. 

It is paramount to capture that data quickly and easily, as well as to be able to apply analytics, notice trends, and address changes in a person’s social risk.

SDOH data empowers providers to identify and address health disparities. It also supports quality measurement, new social needs interventions, and tracking outcomes.

Assessing SDOH barriers to care

The evidence-based health risk assessment within ThoroughCare covers all requirements to screen for SDOH issues that may hinder a patient’s health. Patients can complete a questionnaire online, in your office, or over the phone. 

The SDOH questionnaire contains a health-related social needs section. It asks about living conditions, food access, transportation, utilities, and safety, and it also asks additional questions to help address unmet needs. 

While certified clinical workers are considered qualified personnel to carry out the assessments, it’s important to check with your state’s licensing rules. 

Because ThoroughCare automatically connects HRA answers to the patient’s care plan, the care team can provide follow-up referrals for preventive services or community resources. They can also document additional support, services, and condition education.

Addressing SDOH needs 

Because social determinants create barriers to accessing care and can thwart a patient’s best efforts, addressing them complements the goals of care management programs. 

Care management offers unique features to help patients realize their health goals with confidence, including:

ThoroughCare supports SDOH assessment 

Our care coordination and care management platform offers two ways to engage the built-in, evidence-based SDOH health screening tool: the Annual Wellness Visit within the Wellness module and the HRSN assessment within the Assessment module.

The health risk assessment and SDOH screening help the care team identify patient-specific issues, prompting clinicians to ask more targeted questions and comprehensively assess the patient's environment. 

ThoroughCare’s seamless workflow, robust analytics, and integrated data enable care managers to partner with patients toward action, including:

  • Using automated care planning tools to identify support and health concerns
  • Create or update care plans to address SDOH issues, such as transportation
  • Leverage platform features like barriers and interventions to identify and address SDOH concerns effectively
  • Offer educational support through various resources, including videos, handouts, and pictures
  • Provide comprehensive educational assistance

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