Improving SDOH Collection and Usage: Success Stories from Three Health Systems

With widespread evidence showing the link between overall patient health and social determinants of health (SDOH), organizations across the healthcare spectrum are zeroing in on improving their collection and use of SDOH data.   

But despite broad agreement about the importance of SDOH data, efforts to capture and use such information widely differ, says Lauren Riplinger, JD, AHIMA chief public policy and impact officer.

Some larger entities for example, have successfully connected SDOH efforts to their broader mission as a healthcare organization and are making great strides to drive fundamental change, Riplinger says.

“Conversely, we hear from folks, whether it’s rural hospitals, long-term care facilities, small doctors’ offices, or mid-sized practices where this work hasn’t advanced as much,” she says. “Everyone’s at a different point on this journey.”   

Various challenges contribute to the differing levels and successes of SDOH efforts.

From an organizational perspective, a top challenge is ensuring all staff understand the importance of collecting, sharing, and using SDOH data, says Riplinger. Creating sustainable SDOH interventions and making sure such efforts stay at the forefront of daily workflow also present challenges. 

Health information (HI) professionals face their own unique obstacles, Riplinger adds. Namely, making sure they’re part of SDOH conversations at their organization and that when the data is collected, it’s clear, accurate and HI teams have access to it.

“We know that that data is used downstream for analytics purposes and other uses and to make not only organizational decisions, but in the longer term, to help inform community and policy decisions at the state, local, and federal level,” Riplinger says.

To raise awareness of how SDOH data can improve health and healthcare outcomes, AHIMA launched Data for Better Health. As part of the effort, AHIMA is convening experts, highlighting best practices, and gathering lessons learned about SDOH from leaders across the field. 

Here, health information leaders at three health systems discuss how their organizations addressed SDOH barriers and found unique ways to improve SDOH data collection and usage at their workplaces. The HI professionals will share more about their work during presentations at AHIMA24 iOct. 27-29 in Salt Lake City.  

Using Data to Take Action

About five years ago, the Joint Commission and other regulatory agencies were taking a hard look at how accredited healthcare organizations were providing equitable care, recalls Maria Caban Alizondo, PhD, MOL, RHIT, FAHIMA, director of health information management services for UCLA Health System in Los Angeles.

As a proactive step, UCLA Health leaders decided to examine their own equitable care efforts and how they might improve, says Alizondo. They started by examining what SDOH data they had already collected and how staff were incorporating Z codes.

“We wanted to do a better job at assigning those codes,” Alizondo says. “That meant we had to bring our clinical coding team to the table along with our providers to have those discussions. One of the things we learned was they weren’t able to code it because they couldn’t find the language that would support the [Z] code in the record.”

Leaders started working with clinicians and coders to rectify the problem. UCLA Health also began educating staff across the health system about the significance of health equity and SDOH data, Alizondo says. From frontline staff, to clinicians, to HI professionals, it was essential that all workers were engaged and trained in equitable care, she says.

Using SDOH data, the UCLA Health team examined the populations they served and used the information to identify and understand the social drivers impacting the health of patients. Leaders searched for opportunities to grow current programs and implement new health equity initiatives, Alizondo says.  

The analysis led to a range of outreach programs including UCLA Health’s Gender Health Program, which focuses on ensuring all patients have access to compassionate inclusive, equitable care and The EMPWR Program, an initiative designed to promote wellbeing and resilience in LGBTQ+ children, teenagers, and adults. In addition, UCLA leaders created the Homeless Healthcare Collaborative, a program aimed at promoting greater health equity and clinical outcomes for people who are homeless. 

As part of the Homeless Healthcare Collaborative, mobile clinics travel directly to areas where homeless people are living and deliver care seven days a week. Since 2022, the program has achieved more than 27,000 patient encounters, Alizondo says.

Meanwhile, collection of SDOH has vastly improved at UCLA Health with the system’s clinical coding, performance analytics, and informaticist teams paving the way for better collection and sharing of SDOH data, she says.

“The impact of improved data collection and use of this data to understand patient and community needs has impacted our patients and their outcomes in positive ways, primarily by providing more access [to care],” she says.

In July 2024, UCLA Health received Health Care Equity certification from the Joint Commission. The certification recognizes hospitals that are leading healthcare equity through leadership, collaboration, data collection, provision of care, and performance.

“Through our rigorous data-collection methods, which monitor patient demographics and social drivers of health, we ensure compassionate, safe, and high-quality care for all patients,” Medell Briggs-Malonson, MD, chief of health equity, diversity, and inclusion for UCLA Health said in a press release. “Our commitment is fortified by our collaborative partnerships and strategic initiatives aimed at achieving positive health outcomes for everyone.”

For health systems that want to tackle similar work, Alizondo suggests leaning in on the expertise of clinical coding professionals. Find opportunities to ensure documentation in the record identifies SDOH in ways that coding teams can locate and codify for reporting, she says.  

“Health information professionals are the catalysts for this work because we are integrated throughout healthcare systems, our work touches the experience of every encounter a patient has, and our advocacy can help support efforts in our organization and communities,” she says.

Hear more from Alizondo and Riplinger at AHIMA24 on October 28 at 3:45 p.m. MT.

Digging Deeper to Find ‘Gems’

When the University of Utah Health (UHealth) began studying the social needs of its patient population in 2017, researchers made a stark finding: About 40 percent of emergency department patients had one or more social needs.

The needs varied greatly, however, says Andrea Wallace, PhD, RN, FAAN, associate dean for research at the University of Utah College of Nursing.

Pediatric families, for example, reported greater needs for childcare and eldercare, while Spanish speakers reported much greater need overall, says Wallace. Assistance preferences also differed. Some patients wanted help for their needs, while others did not engage with the services offered.    

Based on its findings, UHealth leaders in 2022 put in place SDOH screening protocols as part of routine pre- and post-natal care in its women’s and children’s services unit. In 2023, data collection and capture processes were expanded to inpatient settings across services.

As part of the effort, leaders integrated search terms within UHealth’s homegrown electronic system to flag patient charts in which SDOH needs may have been missed.   

Such missed SDOH opportunities are where Andrea Dahl, MS, RHIA, CDIP, comes in. Dahl, CDI quality liaison for UHealth, reviews the patient charts that have been flagged to determine whether SDOH-related codes may be applicable. For instance, the notes may mention homelessness, divorce, or transportation struggles, she says. If validated, Dahl sends a notification to coders to review the case for proper Z-coding.

In one case, a progress note mentioned a patient expressing “hopelessness” because he could not care for himself, but was unable to afford a care facility, Dahl recalls. The patient also discussed being banned from a homeless shelter due to drinking, according to the documentation. In another note, Dahl read about a patient living in a trailer with no running water who expressed having limited resources.  

“Within progress notes, some of which are not reviewed on a consistent basis or not noticed for the gems that lie inside, opportunities to assign additional codes for social risks may arise in painting a more complete picture of the daily challenges some of our patients are facing,” Dahl says.

By sifting through the details, Dahl has helped UHealth identify more cases that can be coded for social needs.

“Some of this excavation process will be revealed during my [AHIMA24] presentation in hopes of understanding the importance of this search and speeding up the process for coders with tips and tricks,” she says. “Of course, participants will have an opportunity to go on their own dig in groups allowing discussions of their findings.”

Dahl’s advice for other health systems is to invest in training and support staff who will be engaged in SDOH work with patients.

“We spend so much time on the technology and the tools, but we must remember that acting on SDOH needs takes sensitivity, trust, resources, and patience for a good outcome,” she says.

Hear more from Dahl at AHIMA24 on October 28 at 2:30 p.m. MT.

The Importance of Education

When Northwell Health in New York started its SDOH initiative and data collection system eight years ago, there was no blueprint to follow, says Chanice Husbands, MBA, CCS, senior manager of revenue cycle at Northwell Health.

“It started as an idea that we built and improved over time,” Husbands says.

The data collection started in the pediatric setting and quickly pointed to a high number of children and adult patients who were food insecure, says Mazette Edwards, MA, RHIA, CDIP, CCS, assistant vice president for revenue cycle for Northwell Health System. Based on the data, Northwell started a food pharmacy at a Northwell site where food insecurity was most prevalent.   

As the system’s data collection efforts continued however, leaders encountered various challenges. From the screening side, Edwards says there were patient language barriers, patient trust issues, staff training hurdles, and challenges finding staff who wanted to do SDOH work at the pay rate they were receiving. 

Revenue cycle leaders faced hurdles related to unclear documentation and lack of understanding among providers about their role and who was responsible for documenting patient social needs. A common misconception was that only the attending clinician was responsible for documentation, she says.

“We had to educate them that it doesn’t have to be the attending alone that does the asking or the screening, that any healthcare professional can document they had this conversation with the patient or the patient caregiver,” Edwards says.

To help broaden understanding, Northwell Health leaders developed e-learning modules for its health professionals. The modules, easily accessible on tablets or phones, train clinicians on how to identify and document SDOH, she says. When new SDOH codes come out, the system creates new training modules.  

The e-learning modules have resulted in increased SDOH documentation in the medical record across all healthcare providers at Northwell.  

“Having buy-in from the clinical team was very important,” Edward says. “Having buy-in from the revenue cycle team was very important and also from the data analysts. They’re the ones capturing the data that we code and making sure its accurate. It’s not just an individual, it’s everyone working together.”

In addition to food pharmacies, SDOH data has paved the way for many successful initiatives in Northwell Health, including a gun violence prevention program and programs focused on diversity, equity, and inclusion.

“Understanding the needs of our patients, the communities we provide services for, and our obligations as healthcare professionals has catalyzed development programs, expanded our healthcare delivery system, improved social effort in areas such as maternal health and disparities, and improved collaboration amongst providers and patients focusing on a holistic approach to patient care,” Husbands says.

Hear more from Husbands and Edwards at AHIMA24 on October 29 at 2:45 p.m. MT.

Alicia Gallegos is a freelance healthcare journalist based in the Midwest.