Teaching students to identify and document social determinants of health

Figures & data

Table 1 Proprietary social determinants of health diagnosis and procedure codes defined

Diagnosis Code	Definition
Poverty	Income below poverty line; lack of basic needs such as nutrition, clothing, shelter.
Near Poverty	Just enough money to meet basic needs but not enough for extras. Qualifies for sliding fee discounts at Federally Qualified Health Centers.
Food Insecurity	Does not have reliable access to sufficient quantity of affordable, nutritious food. Does not know where next meal is coming from. May live in food desert.
Experiencing Unstable Housing or Homelessness	Does not have permanent housing, may live on the streets, in a shelter, mission, abandoned building, vehicle or any unstable non-permanent situation.
Poor Quality Housing	Living in housing unit with physical problems (deficiencies in plumbing, heating, electricity, hallways and upkeep) or the presence of negative characteristics (evidence of rodents, water leaks, peeling paint, absences of working smoke detector).
Lack of or No Insurance	Either no health insurance or has insurance which is not sufficient to cover medical expenses or doesn’t cover medications. Prohibits seeking care or follow through.
Lack of Access to Healthcare	Living in a medically underserved area where access to primary care and other services is limited.
Health Literacy Limitations	Not having the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.
Unemployed or Underemployed	Being unemployed or having employment which is insufficient in some way including low pay or unavailability of hours to work.
Unstable Work Schedule	Difficulty scheduling or keeping appointments due to variable work schedule; multiple jobs, varying start/stop times, long shifts or unsure when will work. Person may be a migrant worker who relocates frequently due to work availability.
Family Care Demands	Responsibilities at home caring for others (children, partner, parents, and family) which prevent person from caring for themselves.
Transportation Issues	Hard to get to appointments due to lack of transportation. Does not own vehicle, can’t afford public transportation, lives far from public transportation or services unreliable.
Educational Limitations	Observed difficulty processing and understanding information. Can include difficulty reading, listening, asking questions or applying information.
Language Barriers	Primary language not English; inability to communicate freely and openly with provider.
Cultural Barrier	Cultural background is not in concordance with Western Medicine. May believe Western Medicine can be detrimental or is the place of last resort. Beliefs may conflict with medical care - prohibit patient from seeking care or adhering to treatment plan.
Immigrant Status	Not born in US, now living here legally or illegally. Can have difficulty obtaining public assistance if “illegal”. May be child with legal status whose parents do not have legal status.
Poor Neighborhood Composition	Not feel safe going outside in neighborhood, threat of crime/violence. Under stress from environment. Children can’t play outside, can’t exercise, hard to get to appointments.
Social Isolation	Lacking a sense of belonging socially, lacking engagement with others, has a minimal number of social contacts and is deficient in fulfilling and quality relationships.
Procedure Code	Definition
Crisis Intervention	Immediate, short-term help to resolve emotional, mental, physical and behavioral distress or problems.
Educational Materials Provided	Provision of materials to help educate on conditions, medications, treatments, services, etc.
Extended Appointment Time	Patient encounter lasting beyond regularly scheduled appointment time.
Family Counseling	Working with a whole family unit to improve communication, resolve conflicts and encourage changes for a healthier lifestyle.
Lifestyle Counseling	Working with a patient to improve healthy choices and discontinue habits that may be impeding health.
Referral to Health Center Services	Referral to a service or program offered within the health center.
Referral to External Services	Referral to a service or program provided by external institutions.

Table 2 Comparison of social determinants of health (SDH) codes and ICD 10-CM Z-codes

Applicable ICD-10 Codes	Comparisons
Poverty
Z59.5 Extreme poverty	Removal of the word extreme may make the ICD-10 code more applicable to a larger range of individuals who may need services or assistance.
Near Poverty
Z59.6 Low income	Relatively good match.
Food Insecure
Z59.4 Lack of adequate food and safedrinking water	Relatively good match. It would be advantageous to have additional codes which address ability to afford food separately from food access.
Unstable Housing or Experiencing Homelessness
Z59.0 Homelessness Z59.1 Inadequate housing	Relatively good matches. It may be advantageous to combine the ICD-10 codes into one code as a patient’s living situation may change regularly and the health implications remain the same.
Poor Quality Housing
Z59.8 Other problems related to housing and economic conditions Z59.9 Problem related to housing and economic conditions, unspecified	ICD-10 codes are too general to be actionable. One, more specific code would allow better identification of issues related to housing conditions which may be impacting health.
Lack of or No Insurance
Z59.7 Insufficient social insurance and welfare support	ICD-10 code does not directly reference health insurance.
Lack of Access to Healthcare
None Identified	A code related to healthcare access could help identify patients who do not regularly receive medical care and may be unable to easily meet with specialists or receive regular preventive services.
Health Literacy Limitations
None Identified	Health literacy is an important issue and should be identified separately from education level. Level of health literacy should be considered for all patients and a specific code could help identify those who may be at-risk of non-compliance due to lack of understanding.
Unemployed or Underemployed
Z56.0 Unemployment, unspecified Z56.89 Other problems related to employment Z56.9 Unspecified problems related to employment	Relatively good matches. The addition of underemployed allows identification of patients who may be employed but are not earning enough income to able to meet all of their basic needs. One code addressing insufficient level of employment, could apply to more individuals both unemployed and underemployed.
Unstable Work Schedule
Z56.3 Stressful work schedule	Relatively good match. ICD-10 code may include schedules which are consistent but perceived to be stressful, whereas the SDH code accounts for work schedules which fluctuate, inhibiting ability to plan health appointments. Suggest combination of stressful and unstable work schedules into one code.
Family Care Demands
Z63.6 Dependent relative needing care at home Z63.72 Alcoholism and drug addiction in family Z63.79 Other stressful life events affecting family and household Z63.8 Other specified problems related to primary support group Z63.9 Problem related to primary support group, unspecified	Relatively good matches. ICD-10 codes may be overly specific. One code which encompasses family circumstances which prevent a patient from properly caring for themselves may be easier to document and follow-up on. The codes need a connection to the effect on the patient’s own health.
Transportation Issues
None Identified	Lack of transportation is commonly identified as a social determinant of health and plays a paramount role in a patient’s ability to seek medical care. Documenting this may help patients receive services to assist with transportation.
Educational Limitations
Z55.0 Illiteracy and low-level literacy Z55.1 Schooling unavailable and unattainable Z55.2 Failed school examinations Z55.3 Underachievement in school Z55.4 Educational maladjustment and discord with teachers and classmates Z55.8 Other problems related to education and literacy Z55.9 Problem related to education and literacy, unspecified	Relatively good matches include 55.0, 55.8 and 55.9. Issues relating to literacy are included as part of the SDH code and may not need a separate code. The remaining codes are most likely relevant to children only and are overly specific. The SDH code could be made into two codes, one specific to adults and one specific to children.
Language Barrier
None Identified	It is not uncommon for patients to speak a primary language different to their provider. This barrier to communication should be an important consideration and documentation of it may help place patients with translators or providers who may be better able to communicate with them.
Cultural Barrier
Z60.3 Acculturation difficulty	Relatively good match. The SDH code is better suited to identify patients who have beliefs or customs prohibiting them from complying with medical treatment or recommendations. This is important to distinguish as it directly impacts a patient’s health decisions.
Immigrant Status
None Identified	Although not inherently a source of issue, it is important to document the residency status of patients who have immigrated, as they may have limited resources due to their status. Logging of this code may facilitate connection to available resources.
Poor Neighborhood Composition
Z59.2 Discord with neighbors, lodgers or landlord	The ICD-10 code is one issue which may contribute to poor neighborhood composition, but does not address other potential issues such as neighborhood violence, lack of recreational area or environmental pollution. The SDH code allows for greater identification of patients who may be experiencing issues in their neighborhood not commonly discussed.
Social Isolation
Z60.2 Problems living alone Z60.4 Social exclusion and rejection Z60.8 Other problems related to social environment Z60.9 Problem related to social environment, unspecified	Relatively good matches. The SDH code may be applicable to a greater number of patients who might not overtly express discontent or trouble with being alone, but may be at-risk for such issues due to a lack of support.
Other
Z56.1 Change of job Z56.2 Threat of job loss Z56.4 Discord with boss and workmates Z56.5 Uncongenial work environment Z56.6 Other physical and mental strain related to work Z56.81 Sexual harassment on the job Z56.82 Military deployment status	This selection of ICD-10 codes is worth considering and could perhaps be included in an additional SDH code related to work conditions.
Z57.0 Occupational exposure to noise Z57.1 Occupational exposure to radiation Z57.2 Occupational exposure to dust Z57.31 Occupational exposure to environmental tobacco smoke Z57.39 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.5 Occupational exposure to toxic agents in other industries Z57.6 Occupational exposure to extreme temperature Z57.7 Occupational exposure to vibration Z57.8 Occupational exposure to other risk factors Z57.9 Occupational exposure to unspecified risk factor	This selection of ICD-10 codes is important, but addresses environmental rather than social factors. These codes would be improved with the inclusion of similar exposures in the home environment.
Z59.3 Problems related to living in residential institution	This ICD-10 code addresses an important issue relevant to individuals in the foster system and those in treatment at hospitals or clinics. However, the implications extend beyond living situation. A SDH code related to adverse experiences should be considered.
Z60.0 Problems of adjustment to life-cycle transitions Z60.5 Target of (perceived) adverse discrimination and persecution	This selection of codes describes issues related to social environment and could be included in a SDH code related to lack of social support.
Z62.0 Inadequate parental supervision and control Z62.1 Parental overprotection Z62.21 Child in welfare custody Z62.22 Institutional upbringing Z62.29 Other upbringing away from parents Z62.3 Hostility towards and scapegoating of child Z62.6 Inappropriate (excessive) parental pressure Z62.810 Personal history of physical and sexual abuse in childhood Z62.811 Personal history of psychological abuse in childhood Z62.812 Personal history of neglect in childhood Z62.819 Personal history of unspecified abuse in childhood Z62.820 Parent-biological child conflict Z62.821 Parent-adopted child conflict Z62.822 Parent-foster child conflict Z62.890 Parent-child estrangement NEC Z62.891 Sibling rivalry Z62.898 Other specified problems related to upbringing Z62.9 Problem related to upbringing, unspecified	This selection of ICD-10 codes includes childhood and family difficulties worth considering. These could be included in a SDH code related to adverse experiences.
Z63.0 Problems in relationship with spouse or partner Z63.1 Problems in relationship with in-laws Z63.31 Absence of family member due to military deployment Z63.32 Other absence of family member Z63.4 Disappearance and death of family member Z63.5 Disruption of family by separation and divorce Z63.71 Stress on family due to return of family member from military deployment	This selection of codes describes issues related to family circumstances and could be included in a SDH code related to lack of social support.
Z64.0 Problems related to unwanted pregnancy Z64.1 Problems related to multiparity Z64.4 Discord with counselors Z65.0 Conviction in civil and criminal proceedings without imprisonment Z65.1 Imprisonment and other incarceration Z65.2 Problems related to release from prison Z65.3 Problems related to other legal circumstances Z65.4 Victim of crime and terrorism Z65.5 Exposure to disaster, war and other hostilities Z65.8 Other specified problems related to psychosocial circumstances Z65.9 Problem related to unspecified psychosocial circumstances	This selection of codes includes various issues related to psychosocial circumstances. Their inclusion in factors related to social determinants of health is worth considering.

Table 3 Counts of all codes logged: proprietary social determinants of health (SDH) and ICD 10-CM Z-codes

Codes	Project year 1	Project year 2
Unique Codes Logged	812	13,530
Total Codes Logged	410,142	333,530
Unique Students Logging SDH Codes	193	181
Total Proprietary SDH Diagnosis Codes	12,765	11,808
Poverty	636	601
Near Poverty	493	477
Food Insecure	238	219
Unstable Housing or Homelessness	1579	1486
Poor Quality Housing	407	376
Lack of or No Insurance	602	550
Lack of Access to Healthcare	443	399
Health Literacy Limitations	1211	1106
Unemployed or Underemployed	511	479
Unstable Work Schedule	154	143
Family Care Demands	486	448
Transportation Issues	453	401
Educational Limitations	1083	1001
Language Barrier	1278	1203
Cultural Barrier	597	562
Immigrant Status	448	415
Poor Neighborhood Composition	255	235
Social Isolation	421	391
Other	1470	1316
Total Proprietary SDH Procedure Codes	5,040	3,798
Crisis Intervention	42	33
Education Materials Provided	1000	963
Extended Appointment Time	3	3
Family Counselling	454	414
Lifestyle Counselling	1956	1691
Referral to CHC Services	316	308
Referral to External Services	1269	386
Total ICD-10-CM Z-Codes	ICD Codes Not Available	745 (64 unique codes)

Table 4 Survey response rates by class and project year

Class	Project year 1		Project year 2
	Program year	Response rate	Program year	response rate
2016	4th Year	72 (67.6%)	n/a	–
2017	3rd Year	83 (77.6%)	4th Year	51 (48.6%)
2018	2nd Year	86 (79.4%)	3rd Year	64 (59.8%)
2019	1st Year	77 (70.0%)	2nd Year	61 (47.3%)
2020	n/a	–	1st Year	45 (42.1%)
TOTAL		318 (73.66%)		221 (51.51%)

Table 5 Survey items and response proportions by project year

Survey Item	Project year 1			Project year 2
	Response
	Disagree	Neutral	Agree	Disagree	Neutral	Agree
I am familiar with the social determinants of health (SDH) concept	0.31%	2.83%	96.6%	0.45%	0.45%	99.10%
It is important to address the role of SDH when providing care to patients	0%	1.78%	96.23%	0%	2.6%	98.65%
Logging SDH into the electronic health record is important to the health of patients	5.35%	13.69%	81.0%	2.60%	12.17%	85.22%

Table 6 Survey items and response means by class and project year

Q1. I am familiar with the Social Determinants of Health (SDH) Concept.
Class	Project year 1		Project year 2		p
	n	Mean	n	Mean
2016	72	4.63	n/a	n/a	–
2017	83	4.66	51	4.69	0.3963153
2018	86	4.64	64	4.75	0.0938384
2019	77	4.44	61	4.56	0.0938384
2020	n/a	n/a	45	4.56	–
TOTAL	318	4.59	221	4.64	0.1564796
Q2. It is important to address the role of SDH when providing care to patients.
Class	Project year 1		Project year 2		p
	n	Mean	n	Mean
2016	72	4.49	n/a	n/a	–
2017	83	4.62	51	4.55	0.25337616
2018	86	4.64	64	4.63	0.43918941
2019	77	4.62	61	4.69	0.43918941
2020	n/a	n/a	45	4.69	–
TOTAL	318	4.59	221	4.64	0.18632202
Q3. Logging SDH factors in the medical record is important to the health of patients.
Class	Project year 1		Project year 2		p
	n	MEAN	n	MEAN
2016	72	3.89	n/a	n/a	–
2017	83	3.93	51	4.06	0.19981887
2018	86	4.15	64	4.19	0.39070199
2019	77	4.39	61	4.00	0.00144404
2020	n/a	n/a	45	4.44	–
TOTAL	318	4.09	221	4.17	0.17589849

Table 7 Open-ended responses to the question “Do you feel the request for you to code SDH was beneficial to your undergraduate medical education?”

Positive

1. Documenting SDH helps me remember patients in a deeper way.

2. Identifying and addressing SDH can make a huge difference in patient care and bring awareness to non-medical factors.

3. Documenting SDH keeps these issues on the forefront of my mind and is a great reminder to address the needs of the whole person. It is a constant reminder of how many SDH are present in all patient interactions.

4. It can help with tracking SDH and impact the effect from other comorbidities. It helped establish relationship between factors and helped me determine the overall health picture for patients.

5. Coding SDH can make a difference in our approach to patient care. The more you apply something, the more it is ingrained in your practice for the future.

6. Coding SDH made me even more familiar with important things I need to remember about my patients. This coding is a constant reminder that will shape my career. Like anything in medical school, repetition is the key to success.

7. It allowed me to address other areas that might limit the patient’s ability to seek care or afford the current care. By addressing these areas you may enable the patient to follow a care plan.

8. It highlights the importance of considering SDH while providing care. It adds depth to a generic coding system and made me more cognizant of these factors during patient encounters.

Neutral

1. E*Value is difficult to use and time consuming.

2. We already spend a lot of time on web-based tasks, I am already aware of SDH.

Negative

1. I already know about SDH and coding doesn’t help me know more or do more for patients. I would identify and address SDH without the need to code.

2. Spending time coding takes time away from patient care.

3. It is not applicable to billing so there is no point in coding the SDH.

4. SDH are too subjective and can cause bias.

5. We get significant training in SDH, other physicians don’t code SDH.

6. There isn’t enough time to address SDH during a patient exam

Abbreviation: SDH, social determinants of health.