A Long Journey: Origins of Social Workers as Social Determinants of Health

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Original story posted on: March 5, 2018

The American Hospital Association (AHA) recently announced that notes from social workers and registered nurses will be considered social determinants of health (SDoH).

In 1945, World War II was ending, soldiers were returning home, and my mother graduated from nursing school. Her nursing board exam review book is short; the answer to most questions seems to either be nausea, vomiting, or diarrhea. The pharmacology section can be summed up by Digoxin. She boiled her glass needle and filed it to keep it sharp. Plastic catheters had not been invented yet, so the doctors used metal catheters to administer IV fluid. A good nurse was someone who listened to her patients, served as their cheering section, took them out in the sunlight in the daytime, and tucked them in bed at night with a massage. The International Classification of Diseases (ICDs) was in version 5. The nation had just pulled together to address the needs of individuals and communities in a time of scarcity following the time of war. 

In the subsequent years, medical advances were exponential. in terms of diagnostic imaging, interventions, pharmacology, and our understanding of the mechanisms of diseases. The health of the community, sunlight, and back massages became a casualty of peacetime. We focused on healthcare by looking down through a microscope at ever-smaller units. The wider context of the community and family became more distant from our focus. Emergency rooms became more crowded as we moved farther away from the cause of the causes of disease, i.e. the social determinants of health (SdoH). Hospitals became busier as the focus shifted more toward addressing end-stage disease than actively pursuing preventative measures.

The 1960s saw the introduction of Medicare and Medicaid, creating the need to use the medical record as the bill, for insurance companies. That bill became increasingly expensive.

The Patient Protection and Affordable Care Act (PPACA) was created to help reduce costs and refocus the emphasis of healthcare. Patients are encouraged to stay healthier and seek care in the outpatient setting. Hospitals became incentivized to reduce 30-day readmissions. Services in the outpatient setting quickly improved and grew to include those addressing congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in management clinics. Like most new programs, great gains were made in the beginning by addressing “low-hanging fruit.”

As time moved on, it became increasingly difficult to show such tremendous gains. It became clear that the largest factor in bringing patients to hospitals are the SDoH. The new field of population health emerged: a time to look broader, not smaller.

Missing from the data today are SDoH. A big part of the reason they are missing is that traditionally, only providers’ notes have been allowed for medical coding purposes, not those from the members of the healthcare system who are more likely to engage patients in conversation in the context of family systems and the community. These include the traditional job categories of case managers, to include nurses and social workers and the upcoming fields of community service workers and peer-to-peer recovery coaches.

The Coding Clinic Editorial Advisory Board guidance allowing the use of non-physician documentation for ICD-10 codes Z55-Z65, the Social Determinants of Health, will add a new layer of understanding to the factors that drive health and disease. It will help to reduce the disparities in healthcare as models of reimbursement evolve to capitalize on the understanding highlighted by the additional data.

SDoH codes could also be called the “stress codes:” stress in the form of relationships, the environment, the community, difficulty learning, difficulty at work, economic stress, or caregiver burden (Z63.6). The Z codes 55-65 reflect stress at the individual, family, and community levels. The added layer of clarity they demonstrate will give policymakers the opportunity to distribute resources at all three levels to promote maximum benefit.

In the mid-1990s, Dr. Vincent Feletti and Kaiser Permanente embarked on the Adverse Childhood Experiences (ACEs) study, which demonstrated a high correlation between adverse experiences in the domains of physical abuse, emotional abuse, and household dysfunction before age 18 with physical and mental health issues in later life. It has been said that our work in acute-care settings can be considered palliative care for the ACEs. Including non-physicians’ documentation for SDoH encapsulates most of the questions asked in the ACEs questionnaire. This gives us the opportunity to expand our knowledge of the correlations between these factors and disease, and potentially bring more resources to the base of the pyramid before we prematurely engage in palliative care for the ACEs.

Words have power. The two sentences of this new guidance provide a tremendous opportunity to shift the very nature of healthcare.

To hear more from Diane, click here to listen to her latest Talk Ten Tuesdays segment about how statistics derived from ICD-10 codes might be a useful way in which data can help combat underlying issues.


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Diane Iverson, RN, BSN, BS, ACM, CCM

Diane Iverson, RN, BSN, BS, ACM, CCM, is an emergency room (ER) case manager at a major university hospital in Baltimore. Previously, Iverson was a clinical documentation integrity specialist (CDIS) at Johns Hopkins Hospital.

Iverson began her healthcare career as a computer programmer, which led to her becoming a bedside nurse, including roles as an agency/travel nurse. Currently, her interest is at the intersection of clinical documentation and case management, with the goal of improving data to more accurately reflect the patient population she serves. As a result, Iverson has been advocating for a revision to the coding guidelines to include documentation from registered nurses (RNs) and social workers for the social determinants of health codes Z55-Z65.

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