How screening for social determinants improved care, cut costs

Andis Robeznieks , Senior News Writer

Expanding health care’s focus to include social determinants of health can improve community well-being and help physician practices improve patient outcomes and reduce emergency department use.

Achieving optimal health for all

The AMA is confronting inequity at the system and community level to bring health equity to marginalized and minoritized communities in the U.S.

That is the experience at Professional Medical Corp. (PMC) network, a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

PMC is composed of more than 200 small, independent practices in Flint and Genesee counties in Michigan that have about 460 physicians. Starting in 2017, the PMC network successfully integrated strategies to address social determinants of health into their workflows and helped get a better understanding of the unique needs of their communities.

“Acknowledging the existence and importance of social determinants of health was key,” Karly Saez, PMC’s operations manager, said during an episode of the “AMA STEPS® Forward Podcast.”

Saez noted that some PMC practices were already collecting patient data on social determinants of health, but each was doing it in its own way and asking different questions.

“We needed a better way to collect, view and analyze the needs of our community,” said Farhan Khan, MD, an internist who is PMC’s medical director.

The network decided to employ a validated, third-party screening tool for all of its practices to use, and then had its practice transformation coaches work with staff to find the best way to integrate the survey into their own workflows. For some, it was building it into EHR templates. For others, it was producing printed copies to provide to patients.

Since 2017, PMC practices have conducted more than 20,000 social determinants of health screenings with more than 17,100 patients. They also partnered with the Greater Flint Health Coalition to connect patients with social services they need.

Launching the effort was helped by a three-year (2017–2019) state grant. During that period, PMC demonstrated a 12% overall lower cost of care and a 15% reduction in emergency department use among its managed Medicaid population. That trend has continued, along with PMC practices maintaining one of the lowest overall rates of ED use in Michigan.

The different domains of the PMC screening tool include questions on:

  • Food security.
  • Education and training.
  • Income.
  • Health care cost issues.
  • Physical and mental limits.
  • Limits on daily living activities.
  • Caregiver responsibilities for family and friends.
  • Housing security.
  • Home safety.
  • Transportation, utilities and mental health.

Patients also were screened for access to clean water—something the Flint community had struggled with since 2014. The water crisis led many residents to develop long-term health issues and a distrust of the health system.

These were topics that practice staff weren’t used to asking about. And often, it was information that patients weren’t used to providing during visits to their doctor’s office. Physician champions who were early adopters of social determinants of health screening helped persuade those who were resistant by telling them how it was helping their patients, Saez said.

Dr. Khan noted that physicians learned things through the screening that never would have come up otherwise about their patients’ food and housing insecurity.

“A lot of patients identified the need for assistance with a utility bill,” Dr. Khan said.

“In winter, keeping the heat on is a basic need—especially in Michigan,” he added. “So we were able to connect them to the resources where they can get some help. We would never be able to learn about issues like these if we didn’t do the screening.”

Making sure patients received the services PMC connected them to in a timely manner also boosted the program’s success. This was aided by a survey question asking: “Are any of your needs urgent?”

Learn more with the AMA about how the PMC network uses screenings to address social determinants of health.

The program is financially viable partially through the appropriate application of care-management codes in the Current Procedural Terminology (CPT®) code set, as well as using the International Classification of Diseases 10th Revision (ICD-10-CM) Z codes that address social determinants of health.

The screening has also helped identify community needs, and PMC has used the data to make decisions on resource allocation and building its care management team.

The program sheds light on community needs for food, transportation and housing assistance as well as higher-than-expected behavioral health needs—even for children.

“It gives us quantifiable data to support and justify more services in our communities,” Saez said. “With those high mental health needs, we built our team up with behavioral health counselors and those behavioral health counselors are providing one-on-one counseling with patients.”