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Aligning social determinants of health work with CMS rules

Adapting to CMS standards for social determinants of health work meant aligning Cedars-Sinai's internal goals with external requirements.

Like many health systems across the country, Cedars-Sinai has been on its social determinants of health, or SDOH, journey long before that work was codified in Medicare rule-making.

Today, CMS requires hospitals and health systems admitting inpatients to screen for five common social determinants of health, but for Katie Hren, LCSW, the associate director of community health at Cedars-Sinai, that work has been the bedrock of social work and nursing for decades.

"I'm a social worker by trade, and so it makes me excited that this is a hot topic, and now there are regulatory requirements coming down the pipeline for this," Hren said in a recent phone call. "But I also acknowledge that we've been doing this; this just has a fancy new word. The functions of social work and nursing have been addressing social determinants of health since their creation."

That experience set Hren and her team in the community health department at Cedars-Sinai up for success as the health system rolled out a social determinants of health screening and referral system. The team started designing the process in 2019 with their eyes set on two leading challenges to social determinants programming: access to social services and clinician workflows.

Building out social services referral networks

Many healthcare organizations have long acknowledged the role social determinants of health play in patient well-being, but they haven't always had the systems in place to address them.

"Many of the things that we're being asked to screen for or identify are not necessarily things that we inherently take care of or fall into the traditional medical model. If you come to us with a broken leg, we're here to fix that broken leg. Now we're being asked to, do you have safe spaces to recreate or rehab your broken leg if you need surgery?"

Does the patient have access to medically tailored meals or good nutrition during recovery? What about access to transportation to follow-up appointments?

Clinicians might be reticent to ask patients these questions if they lack the resources to fill patient needs, data has shown. In a 2023 survey of doctors from the Physicians Foundation, 77% of doctors said that community resources to address social determinants of health are scant. And even when those social services do exist, clinicians lack the information about how to find them.

"We knew that if we were going to screen, we needed to also have solutions," Hren said.

That foremost took the shape of an electronic resource and referral platform that lets providers browse a list of resources to ensure no patient is screened and then left empty-handed.

"That's the lowest level touch of intervention, too," Hren continued. "We also launched a community health worker program where we had someone to take that handoff and follow that patient once they left the four walls of our institution. They do home visits and really handhold to make sure that they get connected to the resources and don't fall through the cracks."

Central to this effort was ensuring there was something in it for the community partners, Hren said, acknowledging that community-based organizations (CBOs) don't always have a healthy or trusting relationship with hospital and health system partners. Cedars-Sinai wanted to turn that dynamic on its head and employed a program manager responsible for eliciting CBO concerns and needs.

Tapping frontline workers for screening planning

With a community health partner network in place, Cedars-Sinai turned its attention to how SDOH screening and referral would affect clinician workflows.

Per the Physicians Foundation survey, 61% of doctors feel like they don't have enough time to adequately screen for and address patient SDOH. However, 87% want that time. The bulk of respondents are aware of the impact social determinants of health have on patient well-being.

"Everybody is strapped for capacity in terms of adding one more responsibility. Our nurses are really strapped for bandwidth. Our social workers are strapped for bandwidth," Hren added. "Just feeling like we have enough internal resources to do it and do it well has been a challenge. We've overcome a lot of those challenges through really great staff engagement and through community partnerships."

Hren and her team started by consulting the providers who would be most affected by a new SDOH screening and referral process. Although top-down enthusiasm from executives is important, it's frontline providers who move the needle.

Cedars-Sinai convened a multidisciplinary operations committee that included social workers, nurses, patient navigators and physicians to guide the SDOH screening process implementation. Committee members helped Hren's team develop and build the screening tool, conceived which questions to ask, identified which staff members were best equipped to screen patients and flagged who would be best for patient follow-up.

"We all know it's important. We all know no one has capacity, but we're going to do it," Hren said, describing the energy in the operations committee. "If we're going to do it, how do we do it well? And how do we do it in a way that you all feel comfortable and meaningful and that it's actually going to add and inform the patient care?"

By engaging frontline workers and not simply relying on executive leadership, Hren said Cedars-Sinai was able to develop a workflow that was amenable to clinicians who are focused on patient well-being.

Adapting SDOH work for CMS policies

This system was launched in 2021 and served Cedars-Sinai well as it continued to move within the population health space.

Then, Medicare dropped the 2024 hospital inpatient prospective payment system (IPPS) final rule, which required all inpatient acute hospitalizations to include SDOH screening. The rule requires screening across five domains: transportation, food, utilities, interpersonal violence and housing.

Although it was a symbolic step forward for the industry to see Medicare put reimbursement on the line for SDOH screening, it did present a challenge for the experts at Cedars-Sinai and other hospitals with an existing SDOH framework. How should the health system reconcile its current SDOH screening process with the new Medicare mandates?

Moving from checkbox to meaningful practice

One thing was certain: Hren and her team at Cedars-Sinai did not want their efforts to screen for SDOH to become a check-box item. They still wanted there to be meaning behind their SDOH work to ensure better patient outcomes.

That meant examining the actual SDOH domains Cedars-Sinai historically screened for and determining how to move forward with the five domains that Medicare requires.

"We did have to grapple with the issue that we're asking 12 questions. We're only required to ask five," Hren recounted. "Do we still assess for these 12 risk categories, or do we switch it to only five?"

A closer look at their existing data helped Hren and her team determine how to move forward to yield the most meaning for the most patients. In the end, the needs Cedars-Sinai patients typically present do not align with those required under Medicare's rules.

"If we don't ask these other questions, we're going to be missing all of these patients and their needs, and they are going to fall through the cracks," Hren asserted.

That doesn't mean Cedars-Sinai doesn't collect information about transportation, food, utilities, interpersonal violence or housing. Rather, they have augmented their workflows to continue their existing screening practices and integrate those domains required under Medicare.

"We went back to our social workers and nursing and physician partners to say, 'we kind of have an out,'" Hren recalled. "And they were like, 'No, we want to do meaningful patient care. We're not going to screen just to check a box, so we're going to keep our screening comprehensive. We're going to keep asking for these 12 categories, and we'll just figure out our workflow to be compliant.'"

Right now, each individual on the inpatient side gets a social determinants of health screening, and if they screen positive for any need, an automatic referral to social work is placed, Hren explained. Then, the social work team checks in with the patient upon discharge to assess the services necessary to resolve the SDOH need.

For patients assessed as at higher risk of falling through the cracks, Cedars-Sinai refers them to a community health worker who can provide guidance outside of the hospital.

These CMS regulations and the adaptions Cedars-Sinai has made to meet them are in their nascency. Screening across the five CMS-mandated domains was optional in 2023 and only became a requirement at the start of 2024.

As organizations like Cedars-Sinai continue to mesh their existing SDOH strategy with federal policy, they will need to consider how to balance their population needs with regulatory requirements.

Sara Heath has been reporting news related to patient engagement and health equity since 2015.

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