Step Two: Implementing SDOH Screening & Interventions

A Step-by-Step Guide for Arizona Physician Practices

Ready Your Entire Healthcare Team for SDOH Screening from Start to Finish

Addressing and screening for the social determinants of health will require your healthcare team and office staff to follow new processes, connect with patients, offer resources, and potentially follow up afterwards.

Putting a new, practice-wide process in place may seem daunting, especially on top of managing your office and its patient load. That’s why ArMA’s SDOH Center of Excellence has streamlined the project for you, compiling effective, easy-to-understand strategies and structures in one place.

ArMA recommends the “Let’s Take 5 Steps Implementation Guide” for practices working to integrate clinically validated workflow approaches for patient screenings and navigation. Explore it and supplemental resources below.

5-Step Screening Implementation Guide:

Step One: Prepare Your Practice for Screening 

The first step in implementing SDOH screening is preparing your practice and its staff. By clearly communicating your vision to your healthcare team, you can gain buy-in from those who keep your practice running.

If a patient has unreliable transportation, they might miss an appointment. In doing so, your office staff has to follow up, re-schedule, and do additional tasks that limits their time to effectively help run the practice. Screening for SDOH can potentially eliminate some of these disruptions.

Actionable Items for Step 1:  

  • Evaluate your goals — describe your practice’s SDOH efforts, define the scope of the project, and establish specific process and outcome goals – start simple if needed! Paper screening tools work excellently!
  • Consider what kind of screening tool will work best – there will be options in the next step, or you can create your own based on your demographic’s needs.
  • Outline the logistics for implementing the screening process to your team. For example, will you and your team: 
  • Discuss the importance of incorporating screening into the daily routine with your staff.
  • Educate your staff on how to ask screening questions with empathy and clarity. 
  • Assign roles and responsibilities to team members based on their expertise and clearly communicate what is expected of them.

Step Two: Collect Data

The second step in implementing SDOH screening is designing your process for collecting data. Luckily, you don’t need to start from scratch — there are several existing tools to make this step easier. Many electronic health record vendors have created validated screening tools within their platforms, but you can simply have them fill out a paper form if that is easier. It’s up to you! In selecting your tool, consider which will work best for your practice and your community.

Actionable Items for Step 2:

Step Three: Establish a Referral Process

The third step in implementing SDOH screening is establishing your referral process. Identifying and collecting data on your patients’ SDOH is great, but it’s not the end of the project. To successfully drive improved health outcomes, you and your staff must be prepared with an arsenal of resources for referral. You can ensure patients have access to the resources they need by establishing community relationships, adding to your existing referral platform, and more.

Actionable Items for Step 3:

  • Develop relationships with community organizations.
    • ArMA is the largest physician-led organization in Arizona. We offer our members access to an extensive network of physicians, healthcare leaders, and medical organizations. Visit our website to learn more.
  • Compile a database of resources to get your patients help for their particular SDOH barriers.
  • Use a closed-loop referral system so that community organizations can reach out to your patients and get them the resources that they need.
  • Identify a community health manager to assist patients with navigation and access to resources (often available on the CommunityCares platform above).

Step Four: Implement Your SDOH Screening Process

The fourth step is fully implementing your SDOH screening process. After you’ve prepared your practice, identified the right tools, and collected sources for referrals, you’re ready to launch your SDOH screening process. However, you and your team should start small. Make changes incrementally and be open to modifying your workflow as you uncover “lessons learned.”

Actionable Items for Step 4:

  • Test your screening workflow with a paper survey.
  • Engage empathic conversations with patients to collect data, offer resources, and empower them to seek solutions.
  • Seek feedback from patients and staff to understand the effectiveness of the process.
  • Monitor process measures and goals to understand the effectiveness and readiness to scale.
  • Adjust your screening process as needed.

Step Five: Code for Data & Reimbursement

The fifth and final step in implementing SDOH screening is coding for data and possible reimbursement. You have the option to report administering and screening for SDOH through quality payment. Doing so helps establish information and data on SDOH screening and could enable you to receive reimbursement for your time and efforts. Below, find an overview of available coding and reimbursement options. For more information, visit our Reimbursement webpage.

Actionable Items for Step 5:

  • Use the ICD-10-CM coding system, which provides accurate documentation of patient diagnoses, billing and reimbursement, and communication.
  • Report SDOH screenings through quality payment measures.
  • Utilize the new G codes (G0136, G0019, and G0022) for billing SDOH risk assessments and Community Health Integration services. In the ICD-10 code guidelines for mental health, G codes are used to describe nervous system diseases, while Z codes are used to describe situations where a patient needs services but doesn’t have a specific disorder.

Start Step Three of SDOH Screening Implementation

With your SDOH screening process fully implemented, you’re ready to explore SDOH coding and reimbursement.