The conditions in which we are born, live, learn, work, play, worship and age—known as social determinants of health or SDOH—profoundly impact the health of every person and can enhance or limit our ability to live a healthy life. Inequities in social determinants of health contribute to chronic disease disparities in the Unites States among people from marginalized racial, ethnic and social groups, limiting their opportunities to achieve their highest level of health.
Addressing differences in social determinants of health and health disparities starts with ensuring that everyone has access to the resources they need to live their healthiest lives. At RWJBarnabas Health, we use a screening tool developed by the American Academy of Family Physicians called the Social Needs Screening Tool1, which asks patients questions about their housing, food security, transportation access, utilities, child care, employment, education, finances and personal safety. By using this tool, providers can identify community-based resources to help their patients to overcome health risks and improve health outcomes.
The domains covered in the American Academy of Family Physicians’ Social Needs Screening Tool meet the regulatory requirement for the Quality Improvement Program—NJ (QIP-NJ), the Centers for Medicare & Medicaid Services, and accreditation requirements for The Joint Commission.
4 Steps of SDOH Screening and Referral for Inpatients
- Complete SDOH screening upon admission
The patient is screened in EPIC for social determinants of health as part of the admissions intake process. - Refer positive screened patients
Patients who would benefit from support with their social determinants of health are referred to a Care Manager/Social Worker to follow up via EPIC. - Evaluate referred patients
Evaluation and referrals are made through EPIC CRD by the Care Manager/Social Worker. - Provide referral information to patients
Social Worker/Case Manager discusses the support available for and provides referral information to the patient.
Key Takeaways
- Social determinants of health can significantly impact patient outcomes, so identifying each patient’s SDOH needs and addressing them is key, especially as more payers (insurance companies, Medicare and Medicaid) move to value-based payment systems, in which health care providers are reimbursed based on the cost, quality and equity of care they provide.
- Several screening tools are available to help identify social needs and facilitate conversations with patients.
- ICD-10 “Z” codes (Z55-Z65) can be used to document social determinants of health and give providers accurate data on the needs of their patient population.
For more information view Health Equity.
- Social Needs Screening Tool. (2018). In American Academy of Family Physicians. American Academy of Family Physicians. Retrieved July 17, 2023, from AAFP