September 19, 2017

Hurricanes Prompt Urgent Focus on Documenting Social Determinants of Health: Part II

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EDITOR’S NOTE: This is the second installment in a two-part series on the coding and documenting of social determinants of health (SDoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged states of Texas and Florida.

The effects of the recent hurricanes in Texas and Florida continue to be felt.

The days, weeks, and months immediately following the storms provide good opportunity to showcase the benefits ICD-10 codes have in bringing clarity to the picture of the clinical situation at the bedside.   

In the past, the focus has been more on medical diagnoses. ICD-10 helps further refine the picture in terms of psychosocial elements such as the social determinants of health (SDoH). These are really important because they provide the context in which medical diagnoses occur.

The ICD-10 book breaks down hurricanes that correspond to the waves of patients seen in emergency rooms (X37).

The short initial period of the initial phase, X37.0XXA, is currently turning into the second stage, X37.0XXD, when patients likely will begin presenting to the ER with stress-related symptoms such as shortness of breath, chest pain, abdominal pain, and increased accidents because of stress-induced impaired judgement. People also will present to the healthcare system with symptoms less apparently related to stress, for example Takotsubo syndrome (I51.81), which can be a reversible left ventricular dysfunction following sudden emotional stress. Also, more intermediate physiological ramifications of stress can occur, such as a lowered immune response, during which the body is less able to fight off infections.

Stress is known to disrupt the hypothalamic–pituitary–adrenal (HPA) axis. Disruption of the HPA axis can affect patients who have preexisting autoimmune diseases, such as rheumatoid arthritis or lupus, or who may experience increased flares during this time. Stress can also induce anxiety which can exacerbate preexisting mental health issues.

These symptoms occur in the setting of the SDoH, such as problems with housing (Z59) and problems related to employment (Z56), as people sometimes do not know if they have a job to go back to. There are also occupational exposures during cleanup (Z57). Additionally, there are stressors related to reorganizing a support system and coping mechanisms of loved ones within the support system, such as substance abuse or alcohol use (Z63).

In the coming months, during the final stage of the hurricane recovery, the sequale, X37.0XXS, will set in. This period will see the longer-term effects, such as depression, which can lead to social isolation (Z60) and immobility syndromes, which lead can to early institutionalization. These conditions can be compounded by long-term poverty (Z59), some jobs being eliminated (Z56), and newer jobs having different educational requirements that some might not have. 

In summary, it’s very important that the clinical documentation integrity (CDI) community recognize the important role they play, as perhaps “third responders,” thus ensuring accurate documentation and coding so that “big data” has the most comprehensive picture of what the clinician sees at the bedside.

This helps not as much in the present moment, but also in planning for programs and policies in the future.
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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