Developing a program for addressing social determinants of health

Contemporary OB/GYN JournalVol 69 No 1
Volume 69
Issue 1

Explore the role of health care professionals in enhancing women's health by integrating systematic strategies to address social determinants, leveraging screening tools, and embracing data analytics for personalized care and improved outcomes.

The formulation and execution of a strategy aimed at enhancing health care through the discernment of critical factors, coupled with a systematic approach to mitigating the social determinants of health (SDOH), constitutes a priority for numerous women’s health care practices. Medical providers undergo extensive training over several years to proficiently address physical ailments, thereby positively affecting overall health outcomes. However, it has been postulated that SDOH may influence up to 50% of the length and quality of Americans’ lives, which is over double the influence of factors related to clinical care.1 A sophisticated program that delves into these concerns must consider the broader social, economic, and environmental factors that might affect an individual’s well-being. Recognizing and comprehending these elements is beneficial and essential in dispensing personalized and efficacious care. Therefore, it is an imperative call to action that health care professionals and organizations actively engage in addressing these determinants to elevate the standard of women’s health.


  • Social Determinants of Health (SDOH) significantly impact up to 50% of Americans' lives, emphasizing the need for strategic approaches in women's health care.
  • Screening tools, such as PRAPARE, American Academy of Family Physicians tools, and CMS's Health-Related Social Needs Screening Tool, are essential for identifying relevant determinants and can be integrated into electronic health records (EHR).
  • Health care practices face challenges in responding to positive screenings for SDOH, requiring the development of comprehensive resource lists, staff training, and evaluation of available services.
  • Z codes (Z55-Z65) are becoming the industry standard for coding SDOH issues, providing a more accurate representation of circumstances not well-captured by other codes. Educating providers and billing departments on these codes is crucial.
  • Payers are likely to emphasize screening for SDOH, with new measures encouraging interventions for unmet needs. The article underscores the importance of a multi-disciplinary approach, EHR integration, staff training, and community collaboration for effective care improvement in women's health.

The first step is screening patients for proper identification of factors related to relevant vital determinants. The American College of Obstetricians and Gynecologists committee opinion No. 729 recommends screening for factors such as access to stable housing, access to food and safe drinking water, utility needs, safety in the home and community, immigration status, and employment conditions.2 While most physicians believe that SDOH screening is essential, a majority are not confident in addressing these concerns. Hence, using screening tools and embedding them into the electronic health record (EHR) is an essential first step for many practices. Three common screening tools are as follows:

1) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences tool (PRAPARE) includes 15 core questions and 5 supplemental questions;

2) the American Academy of Family Physicians offers short- and long-form screening tools as part of the EveryONE Project, in which the short form includes 11 questions; and

3) the Centers for Medicare & Medicaid Services has a 10-question screening tool, the Health-Related Social Needs Screening Tool.

All 3 screening tools may be self-administered and can be pushed out to patients as a regular part of patient registration. It is incumbent upon health care practices to articulate with clarity the rationale behind collecting information concerning SDOH and delineate how this information will be utilized to augment the quality of care. Moreover, practices should uphold the utmost privacy standards and cultivate an environment where patients feel comfortable providing personal information.

Instructing your medical staff concerning the collaborative methodology required for responding to positive screenings is paramount, specifically to enhance the response to issues pertaining to SDOH. Among the most considerable challenges staff face is the conundrum of conducting screenings without actionable referral responses—a social services disconnect. Moreover, in many circumstances, resources may be scarce or constrained. Hence, it is imperative to adopt a strategy of screening that is accompanied by the development of an exhaustive list of resources, complete with pertinent contacts. These resources should be evaluated for authenticity, potential limitations in the assistance they might afford, and the possibility of their services being overburdened with new referrals. Such scrutiny ensures that the health care practice is not only prepared but strategically positioned to respond effectively to the complex challenges presented by SDOH. Larger practices may consider a patient navigator to improve support and guide patients through the health care system. Finding the appropriate resources is the most challenging part of a program to address SDOH. The Quality Improvement Network-Quality Improvement Organizations has a basic guide that may help you start your efforts. Other resources are and the American Academy of Family Physicians Neighborhood Navigator.

After initiating your program, you must analyze your efforts and focus on your responses. Using data analytics to identify patterns and trends in your population can reconcentrate your efforts to improve outcomes. Appropriate data collection will help provide actionable insights, assist in risk stratification, and allow innovative initiatives to be designed and refined. Data currently can be collected from several sources, each with pros and cons (Table).3

Currently, Z codes (Z55-Z65) are becoming the industry standard for coding issues of SDOH. These codes can more accurately capture circumstances not ideally captured under other codes in the ICD-10 format. Your organization should educate providers and billing departments on these Z codes and increase their use in your EHR with the standardization of workflows. Providers and billing departments should remember that Z codes are supplemental diagnosis codes and should not be commonly utilized for admitting or as principal diagnosis codes as the primary medical reason for an encounter.

Appropriately coding for Z codes for SDOH also may affect payment and reimbursement and is hence incentivized for providers identifying and utilizing these codes and medical decision making (MDM) to bill evaluation and management visits. For 99204 and 99205, which are used for moderate levels of MDM in new patients, and 99214 and 99215 for MDM in established patients, the Z codes may indicate the elevated risk of complications, morbidity, and mortality because of their effects on limiting treatment options and capability in diagnosis. Currently, the Z codes for SODH are incredibly underutilized, as the latest data from 2019 shows that only 1.59% of Medicare Fee-for-Service beneficiaries had claims with these codes. Many states now require managed care organizations or provider networks to screen enrollees for SDOH needs. With the Healthcare Effectiveness Data and Information Set tool applying a new measure for Social Need Screening and Intervention, screening will become more emphasized by payers and used to evaluate provider quality. This measure will assess members screened, using prespecified instruments, at least once during the measurement period for unmet food, housing, and transportation needs, and receive a corresponding intervention within 30 days if they screened positive.4

Screening for SDOH requires an implementation process integrating standard screens into EHR, staff training and preparation of responses, patient engagement, and community collaboration. This multidisciplinary approach allows providers to take a more holistic approach beyond just clinical factors to address the multitude of factors that influence patient outcomes by including social context. The collection of this data is becoming a new standard for quality, becoming embedded in payment methodologies, and is vital for care improvement. These programs are necessary for improving care and outcomes in women’s health, where factors such as income, education, housing, and social support have profound implications for care.

Looking for advice or have a question about practice management in ob-gyn? We want to hear from you! Email your comments and questions to


1. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129-135. doi:10.1016/j.amepre.2015.08.024

2. Committee on Health Care for Underserved Women. ACOG committee opinion No. 729: importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol. 2018;131(1):e43-e48. doi:10.1097/AOG.0000000000002459

3. Ajao Y. Improving social determinants of health data collection for patient-centered care. Cope Health Solutions. February 25, 2020. Accessed October 6, 2023.

4. Reynolds A. Social need: new HEDIS measure uses electronic data to look at screening, intervention. National Committee for Quality Assurance. November 2, 2022. Accessed October 6, 2023.

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