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Addressing Social Determinants of Health in Your Clinic

As a provider-led health plan, we know that trusted providers are uniquely positioned to identify and influence social determinants of health (SDOH). We know that health and well-being needs remain when a patient leaves the clinic. We want to work with you to give your patients access to the resources they need to live their healthiest lives, including through clinical screening and intervention for SDOH.

This approach is also being adopted across Pennsylvania. The Pennsylvania Department of Health aims to “leverage our authority and ability to convene partners to improve Pennsylvanians’ access to affordable housing, food, and transportation. Because once we have assessed a person’s needs, we must have partners to which we can refer that person to help get those needs met.”

Our attention to person-centered care requires cross-community supports, including you. Screening for SDOH will help with identifying needs, connecting resources, and developing interventions.

To assist our providers in screening for SDOH, we’ve outlined some considerations:

What are social determinants of health?
CDC’s Social Determinants of Health Website
SDOH refer to the social, economic, and physical conditions that can challenge access to care and impact a person’s health outcomes. Here are some examples of SDOH domains, but there are others that may be important in your patients’ lives:

  • Affordable childcare
  • Clothing
  • Food
  • Health care
  • Housing
  • Transportation

  • Utilities
  • Economic status and financial strain
  • Education level and access
  • Employment level and access
  • Literacy
Why do you want to implement SDOH screening in your clinic?
CDC Research on Social Determinants of Health
What goals do you want to set when it comes to implementing SDOH screening and intervention? SDOH screening can help you identify the experiences in your patients’ lives that are negatively affecting their health and well-being. Understanding your patients’ SDOH experiences can provide insight and context regarding aspects of their health history, like missing well-visits or poor medication utilization. By collecting data on SDOH, you can identify interventions, resources, or partners that can help patients address their experienced SDOH barriers. This can lead to an increase in access to care.
Who are your clinic champions for developing your approach to SDOH screening and intervention?
In every clinic, some team members may be more engaged in the process than others. It is important to identify your key champions who can move screening and intervention efforts forward. Figuring out how to implement SDOH screenings and interventions means identifying who in your clinic will be engaged in IT considerations, asking screening questions, designing and completing the documentation, making the resource referrals, and following up with patients as needed.
What community resources do you already have in place? What community resources are you missing?
Take stock of the processes and established connections that your clinic already has. Consider the following questions when thinking about your resources:
  • Do you have a directory or online database of community resources already available for patients?
  • What are the common SDOH domains of concern in your patients’ lives?
  • What are you already doing well?
    • documenting your strengths and thinking about how these strengths will fit into your future SDOH workflow can assist in identifying your next steps
  • For resources that you do not have yet, who in your clinic and community can help you identify them?
How will you choose the appropriate SDOH screening tool for your clinic?
There are many validated SDOH screening tools. Some are very thorough, while others are more concise. It is important that you select one that makes sense for your clinic and your resources. Consider the length of the tool, what it covers, how you will include it into your clinic workflow, how the tool will work within your EHR, and the items for which you are currently able to offer interventions.
Where, how, and when should you screen for SDOH in your clinical workflow?
CDC Programs – Addressing SDOH
Think about not only who can champion your SDOH efforts but who will implement the efforts! When, where, and how you screen for SDOH are key questions in identifying your clinic’s process. Some clinics like to include screening as a form to be filled out upon arrival, either on paper or electronically. Other clinics like to have a nurse, social worker, or physician perform the screening during the visit. Once a screening is complete, you will need to determine who will assist the patient and guide them through a discussion about available resources. There is no one right answer for how to screen. Figure out what works best for your clinic and don’t be afraid to make changes!

What technical considerations does your clinic have?

When you submit claims, please add the appropriate supplemental ICD-10 diagnosis codes to indicate SDOH. View our billing guide for examples of ICD-10 codes and descriptions and Healthcare Common Procedure Coding Systems (HCPCs) codes.
Social Determinants of Health Billing Guide (PDF)

Every clinic has their own structure and resources for clinical implementation. Consider the technology you may need to document SDOH screening questions, interventions, and coding, including using ICD10 Z codes and any available G codes. Consider the following:
  • Are you able to incorporate a screening tool in your EHR?
  • Does your EHR already have a screening tool embedded?
  • How will you track screening rates and interventions?
  • What tracking are your payers looking for and how might SDOH screening relate to your incentives from payers?
How can you limit stigma for patients while asking SDOH screening questions?
Consider how you frame the SDOH questions to your patients, whether verbally or in written form. Remember to include language in your tool that every patient is screened because these questions are an important part of everyone’s health and well-being! This framing helps to reduce the stigma around these topics. It is also important to offer your staff additional training on topics like implicit bias.
What training does your team need for success?
It is important that every member of your team understands why SDOH screening and intervention are becoming part of your standard practice. Make sure to train everyone on your goals, your workflow, and your data monitoring, as well as your goals for implementing this process. Rely on your champions to be leaders in clinic trainings and to support your staff as they learn!
How do you evaluate your success?
RHIhub Toolkit – Evaluation Measures for SDOH Programs
Think about the goals that you set in the beginning of your implementation process. How are you monitoring and reviewing your implementation over time? What aspects of your implementation do you want to report to community partners, DHS, or MCOs? Consistent evaluation of your efforts can help you stay on top of your regulatory needs and on your program successes.

You may decide that your clinic needs to focus on only a few SDOH domains to begin with, like food security and housing. That’s OK! Once your clinic is confident in addressing some SDOH domains and your data and referral evaluations meet your measures of success, consider expanding. It is important to be thoughtful about SDOH screening and intervention. By taking strong baby steps, you will develop a foundation that leads to successful leaps!