Tag: ICD10CM Z codes

The U.S. Playbook to Address the SDoH: Launchpad vs. Final Comprehensive Strategy

The White House released the inaugural U.S. Playbook to Address the Social Determinants of Health. The document serves as an important cross-sector guidepost for application, implementation, and action by all involved stakeholders to best serve their patients and communities. But, does the Playbook go far enough to fully address the SDoH? What other opportunities loom?

It’s been another exciting week for those of us taking our daily walk down Social Determinants of Health Lane. The White House released their U.S. Playbook to Address the Social Determinants of Health. The document has captured the industry’s attention, though also yielded some scrutiny.

The Lowdown

The Playbook is a bold undertaking. The document level-sets the massive work engaged in so far to address the health disparities and barriers to care engaged in across the industry. It quotes research and seminal reports citing the clinical and fiscal impact of health inequities faced by society’s minoritized and marginalized populations and providers. This vital foundation also highlights the importance of patient- and family- centric care that heeds the Quintuple and Quintile Aims at micro, meso, and macro levels, and across involved sectors.

For those who want the Cliff Notes version, here you go. Pages 1-18 provide critical information for persons and organizations who seek foundational information on SDoH (e.g., research, definitions, models) and context for them. This is especially valuable knowledge for students, as well as those who might not be as informed on this topic.

For my colleagues who have been in these trenches, pages 18-35 detail the three Playbook pillars with numbered strategic actions to advance each pillar. There is a candid and comprehensive review of the context for each pillar and potential challenges for implementation. Opportunities for Congressional Action are also detailed.

1. Expand data gathering and sharing: Advance data collection and interoperability among health care, public health, social care services, and other data systems to better address SDOH with federal, state, local, tribal, and territorial support.

2. Support flexible funding for social needs: Identify how flexible use of funds could align investments across sectors to finance community infrastructure, offer grants to empower communities to address HRSNs, and encourage coordinated use of resources to improve health outcomes.

3. Support backbone organizations: Support the development of community backbone organizations and other infrastructure to link health care systems to community-based organizations

The Appendics (pages 36-46) discuss how aspects of the Playbook are currently being operationalized using the Whole of Government approach. This section is a ‘must read’ for it provides specific examples to operationalize each action, with further guidance and information for readers on funding opportunities, toolkits with existing screening and assessment resources, and other critical community activities.

To Be Clear

Like most Federal reports and position papers, the Playbook was not developed as a ‘be all to end all’ document. This valuable resource highlights the mandate for all stakeholders and sectors of health and behavioral health services to ensure the most robust and sustainable approach to inclusive care for all populations possible.

How each organization accomplishes this critical priority is on them. Some might have preferred a greater Playbook focus on expanded funding and reimbursement, and that’s one clear opportunity. My take for ensuring organizational success in addressing the SDoH involves ten elements:

1. Take an honest and critical look at their current SDoH priorities.

2. Identify their target populations most impacted and develop means to ensure equitable and accessible care for all persons. This also includes incorporation of quality metrics and relevant outcomes that go beyond length of stay and readmissions to population-specific health priorities (e.g Patient-reported Outcomes Measures).

3. Align all existing inter- and intra-organizational resources and community partners.

4. Utilize and partner on funding access and opportunities; this includes ongoing investment in their communities served, advocacy for appropriate reimbursement (yup, those ICD-10-CM Z codes), and other fiscal imperatives.

5. Ensure appropriate mechanisms for data-gathering, interoperability, and use.

6. Heed industry compliance requirements (e.g., CMS, the Joint Commission, NCQA, NQF) to implement formal patient assessment (or Health-related Social Needs (HRSNs)) intervention, and direct referral linkage.

7. Ensure diverse and sufficient interprofessional staffing who can provide concordant and respectful whole-person care to all populations, which leverages integrated care frameworks and integrated behavioral health models of treatment.

8. Prioritize workforce training on trauma-informed approaches to care, eliminating implicit and explicit biases and microaggressions, and maximizing ethical engagement to enhance patient engagement and treatment adherence versus compliance and resistance.

9. Ensure the alignment and application of Diversity, Equity, Inclusion, and Belonging (DEIB) policies, whereby all patients and the industry workforce feel safe, seen, heard, and valued.

10. Commit to long-term strategic solutioning of the SDoH rather than short-term reactive response.

In Closing

“The Playbook is a launchpad, and not a final comprehensive strategy for addressing the SDoH”. It may not go as far as all stakeholders would like. Yet, the Playbook serves as an important guidepost for necessary cross-sector application, implementation, and action by all entities and individuals to best serve their patients and communities. I trust readers of this post will weigh in with other suggestions, and that input is encouraged. Just remember, final accountability for advancing these efforts is on us all.

Housing Insecurity=Increased Illness Morbidity and Mortality: Solutions Mandated

Despite abundant research on the intersection of chronic illness morbidity, mortality, & homelessness, poor health outcomes related to housing insufficiency continue. The data is meaningless without using it to activate solid solutions.

“Homelessness remains a key social determinant of health, with researchers from the University of California, San Francisco, revealing that individuals who are homeless are 16X more likely to experience sudden cardiac death than those who are not.” This quote appeared in my social media feed last week, and several thoughts immediately popped in my head. First, it had been over a month since I wrote a blog and that needed to be remedied pronto. Next, this topic gave me a mandate to chew on. However, I wondered, if I had missed something in translation. Surely, this topic was not new news. Despite the significance of this new research on the intersection of sudden cardiac death and homelessness, poor outcomes related to housing insufficiency have been long-standing.

Where it Started IS STILL How it’s Going

Housing insufficiency has been among the most frequently researched SDoH, particularly in how it contributes to excessive clinical and fiscal healthcare utilization for patients. I’ve always valued this quote: “While differences in health between housed socioeconomic groups can be described as a ‘slope’, differences in health between housed and homeless people are better understood as a ‘cliff’.”

Persons who are housing insecure face considerable wholistic health challenges across the domains of physical, mental, and psychosocial health. Barriers to care are only exacerbated by the provision of care that can be suboptimal, and is often fueled by implicit bias on the part of providers. This connection leads to lack of trust by the population of practitioners and the healthcare system overall. 

Global mortality rates for those who are housing insecure are far higher than other populations, and impacts every demographic. Research-driven me wanted to share a few items to ponder:

There’s plenty data more where that came from and across every cultural nuance spanning minoritized and marginalized populations (e.g., age, ethnicity, gender, persons with physical, developmental and intellectual disabilities, race, sexual orientation, socioeconomic status, and other groups) . However, amid my profound respect for the research is a valid concern; data is meaningless without using it to activate solid solutions. 

Strategic Solutioning

I posted related thoughts about this topic on LinkedIn earlier in the week. Countless colleagues and thought leaders in this space chimed in to echo similar and strong sentiments. Among the wisdom shared included:

  1. Active implementation and use of ICD-10-CM-Z codes: Homelessness and healthcare have been misaligned for well over my 40-year tenure in the industry. Fortunately the ICD-10-CM-Z code of Z59 for homelessness has morphed into more realistic and reimbursable codes for industry use, with many effective as of October 1, 2023. A big nod to Evelyn Gallego, the Gravity Project, Dr. Ronald Hirsch, Tiffany Ferguson, and other Z-Code warriors for their tireless energies in this space. Despite this progress, I still hear coders, utilization management specialists, and case managers push back on their use. Many are discouraged from using the codes in their organizations in deference to those that reap higher revenue capture. This is short-sighted, if not potentially fraudulent action; can we say “upcoding”? For those who need a refresher, the codes are listed below with a deeper dive available here:
    • Z59.1: Inadequate housing
      • Z59.10: unspecified
      • Z59.11: environmental temperature
      • Z59.12: utilities
      • Z59.19: other inadequate housing
    • Z59.81: Housing instability, housed
      • Z59.811: with risk of homelessness
      • Z59.812: homelessness in the past 12 months
      • Z59.819: unspecified
  2. Greater acknowledgement of and attention to all social drivers of health: For those who not privy to this information, the CMS 2023 IPPS Final Rule mandated that hospitals reporting to the Inpatient Quality Reporting program submit two measures, SDOH-1 and SDOH-2: voluntary for 2023 but required by 2024. We’re all waiting anxiously to see what the penalties for not reporting this data will be, but we can expect they’ll be significant. Joint Commission has also stepped in with standards NPSG.16.01.01 and EP 2 (Notes 1 and 2). You snooze, you lose!
  3. Attention to How Environmental Factors Exacerbate Social Drivers: Evelyn Gallego is the ultimate data mavin for our industry. Emphasis of environmental exposure due to homelessness and sudden death is a population health priority and public health imperative. As a fellow data-geek, I know how use of the data drives making the case to define policy and funding imperatives, so here are my favorites:
  4. Cities Taking Action to Address Health, Equity and Climate Risks: Through the RWJF’s grant-funded project, Cities Taking Action to Address Health, Equity and Climate Change, 6 U.S. cities have been supported to respond to the interconnected challenges of health, equity and the climate crisis with innovative, community-led projects. The cities and their areas include: 
  5. Enhanced Acknowledgement of the Different Types of Homelessness: There is a cultural shift as the industry is being forced to distinguish between types of housing insufficiency, such as acute and chronic homelessness across populations. Innovators working on the front lines of this challenge include Peter Badgley, Jake Rothstein, and John Gorman from Upside I Housing for Health. The National Alliance to End Homelessness continues their tireless crusade to prevent and end homelessness in the US. The National Community Action Partnership’s over 1000 state agencies take an active role in coordinating on housing advocacy and resource provision. FindHelp.org has a dedicated portal on their site for localized housing information.
  6. Expansion of Affordable Housing, Tax Credits, and other Housing Programs: The Center for Budget Priorities continues to advocate in this arena with a litany of recommendations for capital investments at the Federal, state, and local levels:
    • Reducing the shortage of deeply affordable rental housing 
    • Expanding vouchers for housing
    • Implementing a housing developer-focused renters’ tax credit
    • Reversing restrictive local zoning practices
    • Preventing the loss of existing affordable housing
    • Improving the Low-Income Housing Tax Credit program
    • Investing in tribal communities’ housing needs
    • Removing barriers to homeownership
    • Reforming project-based housing programs to encourage higher-quality housing.

Where We Need to Go

I’m just getting warmed up here, though always strive for comprehensive articles. I encourage others to add solid strategies and resources in the comments section of this blog post. Remember, we are made stronger by using the data to advocate for practical and sustainable solutions! Keep fighting the fight #SDoHWarriors.

Leading the Race for Health Equity: Are IPPS 2023 and CMS’s 2022 Strategic Plan Enough?

“Communities take care of their own”; that is especially true in attaining health equity. Was this grand effort by CMS too little, too late? Industry stakeholders have stepped up to lead the efforts for the population, and are now running far ahead of CMS.

News outlets were flush with reports last weeks of the latest happenings in the Social Determinants of Health (SDoH) space. The top stories were all aligned with press releases from the Centers for Medicare and Medicaid Services (CMS) touting efforts to address “Systemic Inequities” as part of their, 2022 Strategic Plan.

The bold effort encompassed: 

  1. Release of the Inpatient Prospective Payment System 2023 Rule, including the health equity trifecta of:
    • Request for public comment over the next 60 days on means to enhance and/or standardize SDoH documentation through data collection of inpatient claims and metrics that analyze disparities across programs and policies, including a request for information related to homelessness reported by hospitals on Medicare claims
    • Update of the Hospital Readmissions Reduction Program (HRRP) to improve performance for socially at-risk populations, and
    • Implementation of “birthing friendly” hospital designations to improve maternal health outcomes and reduce associated morbidity and mortality. 
  2. Commitment by (CMS) to mitigate health disparities through efforts aligned with Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities through the Federal Government.; all CMS offices  are to embed health equity into the core of their work:
    • Aimed to better identify and respond to inequities in health outcomes,
    • Barriers to coverage, and 
    • Access to care.

The means to achieve these efforts included a robust plan that looks great on paper:

  • Close gaps in health care access, quality, and outcomes for underserved populations.
  • Promote culturally and linguistically appropriate services Build on outreach efforts to enroll eligible people across Medicare, Medicaid/CHIP and the Marketplace. 
  • Expand and standardize the collection and use of data, including race, ethnicity, preferred language, sexual orientation, gender identity, disability, income, geography, et al. across CMS programs.
  • Evaluate policies to determine how CMS can support safety net providers 
  • Ensure engagement with and accountability to the communities served by CMS in policy development and program implementation 
  • Incorporate screening for and promote broader access to health-related social needs, including wider adoption of related quality measures, coordination with community-based organizations, and collection of social needs data in standardized formats 
  • Ensure CMS programs serve as a model and catalyst to advance health equity through our nation’s health care system, including with states, providers, plans, and other stakeholders.
  • Promote the highest quality outcomes and safest care for all people using the framework under the CMS National Quality Strategy.

Yet, my antennae shot up while reading one CMS quote:

“ The agency will bring together healthcare stakeholders—including payers—to promote implementing a health equity strategy. The first meeting will address achieving health equity in maternal healthcare, specifically. It will occur during the summer of 2022.”

Time to hurry up and wait. It seems the health equity strategy is not totally defined: shocking, I know! My elation at seeing formal acknowledgement and attention to, systemic inequities, was quickly dashed. Advancing legislation and funding for the SDoH alone will not fully mitigate the gaps in care. Most experts agree these well-intended efforts will fail, unless the systemic biases that have created and perpetuated the SDoH are also addressed. 

CMS will have to do better than introducing a health equity pillar with strategic language. On the other hand:

  • YES, for the $226.5 M announced this week via HHS and HRSA for Community Health Worker training; build that segment of the workforce. The fiscal and clinical impact of CHWs is massive, enhancing discharge planning outcomes, enhancing treatment and resource access to the most at-risk patients and populations, which bridges serious gaps in care.
  • Develop, fund, and maintain the data exchange infrastructure: 
    • Expand and implement more end to end, social risk analytics and assessment programs like those in play by UniteUs, Socially Determined., and 3M.
    • Expand ICD-10 CM Z codes and approve their reimbursement. I cloud the issue with logic, though reimbursing organizations for the blatant impact of the SDoH and MH on healthcare utilization (e.g., length of stay, ED admissions, readmissions, costs) would greatly enhance revenue coding and capture by healthcare organizations. Organizations will use the codes if there is direct fiscal incentive to do so. GO GRAVITY PROJECT !
    • Grow technology programs that directly support my hospital case management colleagues in assessing, referring, and directly connective patients to needed resources, such as FindHelp.
  • Expand, Food is Medicine programs nationwide, along with the means to assess and directly link patients to necessary nutritional resources GO FarmBoxRx, FoodSmart!
  • Grow funding to Community-based organizations, and safety-net programs, as in community action agencies, neighborhood health clinics, and federally qualified health centers: these are the folks in the trenches!

There was a time when, where CMS went (in terms of reimbursement, programming, and funding) the rest of the industry followed. Yet has this trend shifted? Many have heard me say, “Communities take care of their own”; that is especially true in attaining health equity. Was this latest effort by CMS enough? In time, outcomes will tell the story, but for now, industry stakeholders have stepped up to lead the efforts for their communities, and running ahead of pack.

Your comments are valued so feel free to add them below.