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Expert: SDOH assessment needs follow-through beyond documentation

CMS continues to expand its use of social determinants of health (SDOH) in Medicare. Recently the agency made a manual change making an SDOH assessment a payable add-on service with the Medicare annual wellness visit (AWV), as reported in the May 20, 2024, edition of Part B News (subscription).
One question has come up about SDOH assessments: If the provider taking the assessment finds the patient has social issues that should be addressed – e.g. housing status, transportation to health care appointments – is the provider obliged to address them, or simply document them?
We are grateful to Kayla Holgash, health policy director at McDermott+Consulting in Washington, D.C., for her insight. She cites this passage from the 2024 Medicare physician fee schedule final rule:
" … we are not finalizing the requirement that the practitioner who furnishes the SDOH risk assessment must also have the capacity to furnish CHI [Community Health Integration], PIN [Principal Illness Navigation], other care management services, or have partnerships with CBOs [Community-Based Organizations]. We do expect that the practitioner furnishing an SDOH risk assessment would, at a minimum, refer the patient to relevant resources and take into account the results of the assessment in their medical decision making, or diagnosis and treatment plan for the visit."
Holgash explains:
“The rule does not mandate that providers have the capacity to furnish care management services or have partnerships with community organizations, but CMS does expect providers to take the assessment into account for decision-making and refer the patient to relevant resources, which they were already required to do as part of AWVs.
“CMS does not directly discuss having follow-up services available in the AWV section -- but they do note that the ACA and subsequent CMS regulation at § 410.15 established the AWV benefit, which already incorporates the requirement to furnish 'personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.'
"For SDOH risk assessments in relation to CHI, PIN and other care management services, CMS states that follow-up or referral is important. But practitioners may not be ideally suited to solve long-standing SDOH concerns, and CMS is sensitive to the operational needs of practitioners who do not yet have these resources in place and supply issues with community-based organizations."
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