No one knows better than EMS that the conditions of people’s lives have a big influence on their health. For years EMS staff have observed the effect of nonmedical factors like poverty, food insecurity, and lack of social support on a person’s well-being. It is sobering to realize that while the U.S. spends more than $3.5 trillion annually on healthcare ($10,739 per person),1 healthcare accounts for only 10%–20% of a person’s overall health. The rest is determined by social determinants of health (SDoH).2
For a long time there was little discussion or recognition of SDoH and how they might change how we track, deliver, and coordinate care. Healthcare, including emergency medical care, stayed in its own lane. But as healthcare costs go up and the population ages, we can no longer afford to ignore SDoH.
The connection between SDoH and health status has become especially evident during the coronavirus pandemic. Factors such as poverty, race, and zip code have made certain groups more vulnerable to the serious effects of the virus. Economic fallout from the pandemic may leave more people vulnerable to poverty and, in turn, further illness.
It is time for EMS to use its expertise and take a leadership role in creating data systems and referral practices that make the connection between healthcare and the social determinants of health.
What Are the SDoH?
According to the World Health Organization, the social determinants of health are the “conditions into which a person is born, lives, grows, works, and ages” and “the fundamental drivers of these conditions.”3 This definition represents a wide range of personal, social, economic, and environmental factors that impact health on both individuals and populations.
Social determinants include factors that influence health, such as poverty, housing, food security, education and job training, transportation, public safety, social support, social norms and attitudes, exposure to crime or violence, racism/discrimination, literacy, access to communications, and culture. Environmental factors such as access to nature, features of the built environment (buildings, bike lanes, roads) and exposure to toxic substances and other hazards are also part of SDoH.
When we stabilize patients but worry about sending them back into the life situation that is contributing to their poor health, we are acknowledging the social determinants of health.
EMS as a Partner
EMS provides services at homes and in communities and is well positioned to connect healthcare with social and community services. EMS and hospital emergency department personnel see and experience the connections between culture, environment, and health outcomes every day.
“EMS has always seen the extent of the insecurities out there,” says Pat Songer, chief operating officer of Cascade Medical in Washington. “But in the past we weren’t able to connect patients to resources for these core needs that may be creating their health problems. We’d just respond to the current crisis.”
As early as 1998 nurse and public health researcher Ruth Malone observed that “heavy ED utilization, as both a clinical and policy problem, is a function not merely of unmet medical care needs for individuals, but of ‘almshouse’ needs in a changing healthcare context.”4 In other words, it’s not just an access-to-care problem. It’s about unmet social needs and poor living conditions that don’t support health.
Because the social determinants of health can drive overuse of the 9-1-1 system and hospital emergency departments, it is important for EMS and emergency medicine to take a leadership role in communities to address these issues proactively.
Case Study: CARES in Colorado Springs
To address the social determinants of health requires communitywide partnerships. One pioneer in this work is the city of Colorado Springs, Colo. In 2012 the Colorado Springs Fire Department, in collaboration with two local hospital systems, developed a prehospital navigation program called CARES (Coordinated Access Referral Education Services).5 The program has been funded primarily with a combination of city funding, grant funding, and support from the hospital systems (University of Colorado Health and Centura).
CARES is a mobile integrated health program that partners with clinics and agencies across the city to connect high utilizers of the emergency health system with the care they need. It also helps older adults find the services they need to safely age in place in the community, and helps those with serious mental illness navigate the system to find the right support. Specially trained staff identify those who will benefit from the program and offer six months of intensive navigation services followed by six months of monitoring. Participants are proactively connected to medical care, mental health services, and social/community services before their need becomes a 9-1-1 emergency.
This program has become an essential community resource because it addresses both medical and nonmedical needs, and it has been successful. According to the Colorado Springs Fire Department, in 2018 CARES found a 69% reduction in emergency department use by members of the program, and a 73% decrease in 9-1-1 use.6
CARES and other early MIH/community paramedicine programs have revealed two challenges that must be tackled to make it possible for EMS to truly address the SDoH: data-sharing and funding.
Data-Sharing and Referral
If community members are to have their nonmedical needs identified and addressed, the typical healthcare silos will need to be connected with one another and with community and social service providers. It is essential for EMS to be at the table as communities decide how to solve the following problems related to data-sharing and service referrals:
Standardized screening—While clinical guidelines increasingly recommend the SDoH be captured and recorded, there is a lack of standardized screening tools and processes. One study found community health centers in Boston identified 16 domains and 78 dimensions of social determinants of health. Housing was the only domain that all centers screened for. A standardized screening process will help different players across the healthcare and social service systems communicate effectively with one another and allow for a common language about the social determinants of health. Two tools to consider are the Centers for Medicare and Medicaid Services’ Accountable Health Communities tool and the PRAPARE tool from the National Association of Community Health Centers.
Reliable information for referrals—Once you assess for social determinants, you will want to refer community members to medical and nonmedical services that will address those problems. Many communities don’t have a consolidated, updated list of community services and resources. EMS might consider partnering with organizations such as United Way to compile or access such lists.
Referral tracking and results—To measure the impact of EMS programs that address social determinants, it will be helpful to know what happened after someone was referred to a service. This information would also help EMS know who has received what help and who may still need it. This is a tricky problem because many community service providers do not have the expertise or budget to set up secure electronic records systems. EMS should be at the table as communities decide how to share information among service providers.
Attending to SDoH can save money and lives. Due to the historical quirks of healthcare billing, however, it has been difficult to pay for it.7 That may be changing as new revenue streams and incentives emerge. Below are some trends EMS may be able to take advantage of to do this new type of work.
Health insurance reimbursement—Private health insurance companies, Medicare, and state Medicaid programs may decide to reimburse for services related to assessing and addressing SDoH. Currently there are no specific CPT codes (medical billing codes) to bill for SDoH services. While specific codes may eventually be developed, payers may agree to use existing CPT codes for SDoH screening and referral. According to Songer some payers reimburse for SDoH using the health and behavior assessment CPT code. Some payers are asking providers to use the ICD-10 Z-codes (diagnosis codes for SDoH) as a way to document the extent to which how often social determinants are a factor in health problems.8 These codes are not currently as specific as they should be, but new, more specific codes are being developed.9 Such documentation may lead to specific CPT codes and reimbursement. EMS providers who are already advocating to be able to bill for medical services may want to advocate for reimbursement of SDoH as well.
Value-based payments—Some payers are paying for value—the optimal use of health services for the best outcomes—rather than reimbursing for individual services. For EMS this might look like payment for good outcomes rather than payment only for successful transport to a hospital. It may also mean partnering with accountable care organizations or managed care plans, including Medicare Advantage plans, which can offer SDoH services through community paramedicine as an additional benefit to control costs and improve outcomes.
Grant funding—EMS programs may be able to apply for grant funds from community foundations, health foundations, and foundations established by companies (including insurance companies). This is a great way to get the funds needed to establish or expand a program. But grant funding is not usually permanent and often cannot be used for ongoing operating expenses, so plan accordingly.
Public-private partnerships—Healthcare and hospital systems often partner with municipalities to establish or support community paramedicine programs that address SDoH.
EMS providers should be prepared to explore multiple funding sources for SDoH and have the accounting systems in place to manage them.
SDoH and COVID-19
Emergency services might be feeling overwhelmed by the response to COVID-19 and wondering if it’s possible to do this kind of work given the current situation. However, there are specific strategies mobile integrated health can use to continue connecting people with resources during continued physical distancing and stay-at-home orders.
The CARES program had been taking this opportunity to think about new ways to work and connect. “This has certainly caused us to think differently about how we do patient navigation,” says Steve Johnson, community and public health administrator for the CARES program at the Colorado Springs Fire Department. “We’re learning a lot about efficiency and how to reach people in new ways. It will make us a stronger program because it’s teaching us things we wouldn’t otherwise have learned.”
In addition, the COVID-19 pandemic demonstrates the complex relationship between health status and social factors and highlights the need for connecting the two. Poverty leads to both environmental factors and health behaviors that cause poor health and make people more vulnerable to infectious disease. People living in areas with air and water pollution already had the increased heart disease and asthma rates that come from those; such areas also typically are more crowded with denser housing options. Many of the people who live in these areas rely on public transportation for work, making social distancing difficult and increasing the risk of infection. Structural racism, which has contributed to the poorer health status of black and indigenous people across socioeconomic classes, has caused these groups to experience more serious disease and death during the pandemic. And the economic fallout of the virus will likely put even more Americans in such vulnerable positions, perpetuating a cycle of poverty and ill health.
“The ability to go to the doctor, food insecurity, housing problems—everything will be impacted after coronavirus,” says Songer. “Healthcare literacy is another big issue—getting the right education out there. These are things mobile integrated health programs can do. We can help reduce the burden on the healthcare system.”
Now is the perfect time for EMS to join the work being done in the prehospital field to ensure community members get the services they need to address adverse social conditions. With one foot in healthcare and the other in community-based services, EMS is an ideal partner for SDoH work and should be at the table for discussion and development of best practices. With EMS involved in program design from the beginning, SDoH services will be more effective, well documented, and, ultimately, valued.
1. Centers for Medicare & Medicaid Services. National Health Expenditure Data: Historical, www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.
2. Magnan S. Social Determinants of Health 101 for Healthcare: Five Plus Five. National Academy of Medicine, https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/.
3. World Health Organization. Commission on Social Determinants of Health—final report, www.who.int/social_determinants/thecommission/finalreport/en/.
4. Malone RE. Whither the Almshouse? Overutilization and the Role of the Emergency Department. J Health Polit Policy Law, 1998 Oct; 23(5): 795–832.
5. Bronsky ES, McGraw C, Johnson R, et al. CARES: A Community-wide Collaboration Identifies Super-utilizers and Reduces Their 9-1-1 Call, Emergency Department, and Hospital Visit Rates. Prehosp Emerg Care, 2017 Nov–Dec; 21(6): 693–9.
6. Colorado Springs Fire Department. CARES 2018 Report.
7. Health Leads, United Way, 2-1-1. Social Determinants of Health: Overcoming the Greatest Barriers to Patient Care. Health Leads, http://healthleadsusa.org/wp-content/uploads/2018/10/SDOH-Overcoming-the-Greatest-Barriers-to-Patient-Care.pdf.
8. Colorado Office of eHealth Innovation. Working Action Plan and Environmental Scan Report: Support Care Coordination In Communities Statewide, www.colorado.gov/pacific/sites/www.emsworld.com/files/Care%20Coordination%20 Environmental%20Scan%20Action%20Plan%20Final_V3%28002%29%20%282%29.pdf.
9. Robeznieks A. New ICD-10 codes will help physicians tackle social barriers to care. American Medical Association, www.ama-assn.org/practice-management/digital/new-icd-10-codes-will-help-physicians-tackle-social-barriers-care.
Robin E. Johnson, MD, MPH, FACEP, is medical director for El Paso County Public Health in Colorado. She has served 26 years in medical practice and healthcare advocacy in the Pikes Peak region.
Scott Cravens, EMT, is CEO of Julota, a community interoperability platform that manages consent and multidirectional sharing of sensitive information between healthcare, EMS, law enforcement, behavioral health, social services, and other organizations.