Clinic-Based Workflows

Any member of a person’s care team can collect SDOH data during any encounter.

• Includes providers, social workers, community health workers, case managers, patient navigators, and nurses
• Collect data at intake through health risk assessments, screening tools, person-provider interaction, and self-reporting

Record data in a person’s paper or electronic health record (EHR).

• Document SDOH data in the problem or diagnosis list, patient or client history, or provider notes.
• Care teams can collect more detailed SDOH data than current Z codes allow. Keep this data.
• Efforts are ongoing to close Z code gaps and standardize SDOH data.

Study the ICD-10-CM Official Guidelines for Coding and Reporting, available under the ICD-10 Files heading on the CMS ICD-10 webpage.

• Coding, billing, and EHR systems help coders assign standardized codes like Z codes
• Coders can assign SDOH Z codes based on self-reported data or information that any member of the care team documented in a health care record

Data analysis can help improve quality, care coordination, and experience of care.

• Identify people’s social risk factors and unmet needs
• Inform health care and services, follow-up, and discharge planning
• Trigger referrals to social services that meet people’s needs
• Track referrals between providers and social service organizations

Add SDOH data to reports for executive leadership and boards of directors to inform value-based care opportunities.

• Share findings with social service organizations, providers, health plans, and consumer and patient advisory boards to identify unmet needs
• Use a Disparities Impact Statement to identify opportunities to focus on health equity