CMS Rolls Out New Data on Social Determinants of Health in the Home

Earlier this month, the U.S. Centers for Medicare & Medicaid Services (CMS) released a first-of-its-kind report on social determinants of health (SDoH) among Medicare fee-for-service (FFS) beneficiaries.

Home health providers have increasingly turned their attention to SDoH and whole-person care, especially as hospitals and health systems recognize the value of nutrition, transportation and socialization support in avoiding preventable readmissions. Outside of FFS Medicare, home care providers have tuned into the SDoH talk as well, encouraged by emerging opportunities within Medicare Advantage (MA).

Broadly, CMS’s new report is meant to provide quantifiable insights into the prevalence of social determinants of health and to help drive further awareness throughout the continuum of care. The report is based on data from the ICD-10 diagnostic tool’s “Z codes,” which identify individuals with potential health hazards related to socioeconomic and psychological circumstances. 


Overall, the report underscores the value that in-home care providers bring to the table. It also, however, emphasizes the need for better and more standardized reporting of SDoH within the health care sector.

Among the 33.7 million Medicare fee-for-service beneficiaries in 2017, about 1.4% had claims with Z codes, according to CMS. Featured on more than 196,500 claims, “problems related to living alone” was one of the most frequently utilized Z codes.

Utah-based Intermountain Healthcare is just one of the major health systems that have recognized the importance of tackling SDoH. In 2018, for example, Intermountain teamed up with in-home care provider Lifesprk to launch SDoH-inspired joint venture “Homespire.”


“With the addition of our Homespire joint venture, we’re able to wrap all of those services around with activities of daily living and social determinants of health work,” Rajesh Shreestha, chief operating officer of community-based care for Intermountain, previously told Home Health Care News. “That package together, we feel, is the most comprehensive home-based program in the U.S., once this is all rolled out.”

In addition to calling out how many Medicare FFS claims had Z codes in 2017, CMS’s report also flagged a connection between SDoH and many common chronic conditions that in-home care providers help treat.

Of beneficiaries with Z-code claims, 72% had hypertension. Meanwhile, 53% had depression, 38% had chronic kidney disease, 34% had diabetes and 25% had congestive heart failure.

The majority of beneficiaries with claims noting problems related to living alone were 75 or older. Claims for female beneficiaries were far more likely to include Z codes linked to trouble living alone.

More information needed

Despite being a priority for many health care organizations, the bulks of hospitals and physician practices aren’t screening for SDoH. Less than one-quarter of hospitals and 16% of physician practices currently screen for recommended social determinants of health, a 2019 JAMA study revealed.

As a result, CMS’s report is like a drastically underwhelming reflection of the actual SDoH population.

“This [report] provides insight into the limited documentation of social determinants of health for Medicare FFS beneficiaries,” CMS officials noted. “However, more widely adopted and consistent documentation is needed to more comprehensively identify social needs, and monitor progress in addressing them. Collaboration between beneficiaries, community groups, and health care providers will be necessary to adequately address the social determinants of health, and ultimately to improve health outcomes.”

Generally, health care stakeholders have a lack of awareness of Z codes and confusion as to who could document social needs, according to CMS.

Additionally, many are unaware that clinicians other than the patient’s primary provider could document social determinants of health.

Improving SDoH data collection will likely lead to an increase in patient referrals to supportive services — such as in-home care — and help identify population-level trends that have both health and cost implications. 

Companies featured in this article: