Guest post: Social determinants of health for social justice

by Howard Rodenberg, MD, MPH, CCDS

To say it’s a strange time in our nation’s history is an understatement. Never in my half-century of memories have so many Americans pitted themselves against one another, driven by the relentless engines of power and partisanship, placed face-forward by a constant media barrage.

One of my side projects is working with the American Journal of Public Health as part of an informal advisory group of former State Health Officers. (I was director of the Division of Health for the State of Kansas from 2005-2007.) Each of us were recently tasked to write something about our personal response to the racial injustice highlighted by the murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and others. Mine went something like this:

One of the problems that comes with a clinical career in emergency medicine is the need to compartmentalize. It’s a mixed blessing at best, good in the heat of the moment, useless when trying to see the big picture. So, when George Floyd was murdered, the event was distant to me geographically, socioeconomically, and racially. I found a mental compartment for it and filed it away along with a string of other events, lamenting the underlying injustice but not recognizing the depths of such cultural outrage would become a true catalyst for change.

A few weeks later, my son was at a local diner, having lunch and playing on his phone. Of course, his battery ran out. He moved to another booth with an outlet to plug in, recharge, and keep playing. The man in the next booth asked, “Are you moving because I’m black?” Recounting the events to me later, my son said, “It’s sad that we’re in a situation nowadays that that question is perfectly legitimate and needs to be asked.”

It’s not just sad; it’s a terrible state of affairs. It says so much about the lack of trust we have to simply treat each other decently that it’s not just an appropriate question, but the right and needed one as well. And it’s made me think about…well, other questions. Things that I might ask, things that I should ask.

For instance, how can I, as a CDI physician advisor, further a just nation within my scope of work? How can we, as a CDI community, do the same?

It’s important to note what’s already been done. On the national level, ACDIS recently created a Diversity and Inclusion Task Force to ensure the organization is constantly promoting and supporting these key values within our profession. In addition, there’s been a commitment to use the ACDIS Podcast as a forum for discussion of racism in the CDI workspace. These are powerful initiatives, and ACDIS leadership is to be commended for their efforts.

It’s nevertheless crucial to find a way forward on the local level as well. I’m sure that many of us work in institutions that have long-standing diversity programs, designed to help the workforce best reflect the makeup of the surrounding community. More acutely, many of us have also been part of conversations about race, gender, and ethnicity in the workplace, often scripted and supervised by well-intended human resources staff. But I hope I might be forgiven if sometimes it feels like these meetings are more interested in seeming to do something than in forwarding the issue at hand.

What else can we do locally, and as a CDI community as a whole? I believe that a purposeful focus on the social determinants of health is a way to promote justice within the realm of CDI.

A bit of background may be in order. Social determinants of health are those factors that influence health status beyond the simple presence of physical or mental illness. Social determinants include income level, educational achievement, food security, housing status, and social networking.

Fortunately, ICD-10-CM already gives us a way to address these using Z codes in series Z55-Z65. The Official Guidelines for Coding and Reporting make it easy to code this information. It notes that codes within the series can be used for “persons with potential health hazards related to socioeconomic and psychosocial circumstances,” and that code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents “social information rather than medical diagnoses,” (see ICD-10-CM Official Guidelines for Coding and Reporting, FY 2020, 1.B.14.). This is one of those few places that we don’t need the attending physician to document for code to be valid.

The need for more aggressive use of the social determinant Z codes has been well-recognized. Even payers such as United Healthcare (a.k.a. “The Dark Side”) emphasizes the need to record these codes as the best way to truly reflect the patient’s socioeconomic circumstances contributing to their needs for care. The FY 2020 Inpatient Prospective Payment System (IPPS) proposed rule even suggested that code Z 59.0, “homelessness,” would qualify as a reimbursable comorbid condition.

If we want to advance the cause of social justice within CDI, it’s my belief that the best way to do so is to capture the social determinants of health. The data that results from aggressive identification and coding of these social determinants through expanded use of Z codes can help us to capture the hard data needed to overcome opinion and bias. We can then more clearly demonstrate the interactions of race, gender, ethnicity, and other key socioeconomic indicators with healthcare costs, utilization, and outcomes. Data-driven identification of specific health disparities can be used to drive focused efforts to needed change.

The CDI team could work across departments to establish a consistent mechanism for capturing this information. Without a routine ask, this information is likely to be collected erratically, and when it is collected it may appear in in various narratives in physician, nursing, or case management notes. The random placement of this information (when it’s been obtained) makes it difficult to ensure a reliable picture of your patient population. A more efficient means to ensure that social determinants are routinely and reliably collected are to integrate them into nursing admission assessments or into the social history component of a physician note template. It would also be important to focus on Z codes that are more objective in nature, ones that might be answered with a yes/no or a checkbox, I order to avoid difficulties of interpretation for the more subjective codes.

How would you use this information to advance social justice? We might look at length of stay, hospital charges, and mortality rates between self-identified racial groups, levels of education and income, and employment status within a DRG. Finding a disparity between any of these groups of patients is not prima facie evidence of racism, classism, or any other particular “ism.” But it might prompt a review of records to see if there are internal disparities in treatment that must be resolved; if not, the information then helps us to look outside the institution to how we might, as a larger community, resolve more complex societal issues.

Using CDI tools to capture the social determinants of health should be a mainstay of our profession. I truly believe that capturing the social determinants of health can serve as a catalyst to inform our local and national conversation about social justice.

I’m making a commitment to make sure we’re doing so in our hospital. I encourage you to do the same.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.