The Role of Social Determinants – Don’t Let Them DisappearMary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM Cynthia Fleece, RN, ACM-RN, MBA Ronald Hirsch, MD, FACP, ACPA-C, CHRI Beatrice, a 76-year-old female, insured by traditional Medicare A and B with a supplement and no secondary insurance is scheduled to have a total knee arthroplasty. The patient and orthopedist have tried conservative measures, and the patient has tried to delay her surgery as long as possible as she lives alone and is concerned about how she will manage after surgery. The surgeon assures her that the case managers will meet with her after surgery and “everything will be fine.” The surgeon schedules the surgery for the first Friday of the next month as the third case of their day on the OR. The patient arrives for surgery, does well, and after recovery room is sent upstairs to recover overnight. At 3 pm, the case manager on the orthopedic unit gets a referral from the patient’s nurse to see the patient “who is asking about going to a nursing home for her therapy.” The case manager alerts her daughter that she will not be able to make it to her grandson’s high school track meet that afternoon. She goes to the patient room and asks for permission to talk to her. The patient relates that she lives alone in a low-income apartment with four steps to enter from the garage. She recently moved as the rent at her previous location became unaffordable and she continues to worry about making ends meet. The case manager contacts the physician advisor who recalls an article from Dr. Ronald Hirsch that notes that Medicare allows patients who are having joint replacement to be admitted as Inpatient to allow Medicare Part A-covered skilled nursing facility (SNF) access when it is indicated. The physician advisor advises the case manager to contact the surgeon and notes that they are available for support if needed. The case manager contacts the surgeon who provides a verbal Inpatient admission order. The case manager then continues her patient evaluation and determines that the patient lives off her social security check and after paying rent, utilities, and medications, she has little money to pay for the food that she knows she should be eating with diabetes. The patient has an uneventful, albeit slow, recovery and transfers to a SNF with clear need for aggressive therapy to be able to get her back to her apartment. The patient works hard at the SNF and goes home after three weeks at the SNF with home care services ordered. The hospital’s care management team is notified that they have been assigned to participate in the upcoming Centers for Medicare and Medicaid Services (CMS) mandated Transforming Episode Accountability Model (TEAM) bundle payment program starting in 2026. In order to better understand the process, the team reviews the care trajectory of recent patients whose care would be included if surgery occurred in 2026 and reviewed Beatrice’s case. They note that the hospital inpatient claim included ICD-10-CM diagnosis codes for osteoarthritis of the knee and controlled diabetes mellitus. The estimated costs of her 30-day episode of care included her three-day inpatient stay, her 21-day SNF stay and six days of home care services. If she had surgery in 2026, those costs would have been compared to the “expected” costs for a 76-year-old female with diabetes. Yet, Beatrice’s care was not simply about a patient with diabetes and arthritis. She has housing insecurity, income insecurity, and food insecurity. There is no doubt that those factors influenced her care yet no one but the case manager knew that. In addition, if not for the astute case manager who realized on Friday afternoon that the patient would need post-acute care at a SNF, one could imagine what could have happened and it would not have been pretty. It has been proposed in the 2026 IPPS Rule that required reporting of social determinants of health will be eliminated from TEAM, the reality is that these determinants do influence the hospital and post-acute care of every patient as clearly not all Medicare patients are alike. The proposed Inpatient Prospective Payment System (IPPS) Rule will impact both patients and hospitals. Documenting barriers to expected recovery based on chronic illness, homelessness, unsafe home environments, and inability to afford proper nutrition needed to encourage recovery will allow our most vulnerable and fragile patient populations to be admitted as inpatients and prevent surgical complications, such as infections or deep vein thromboses (DVTs) that drive patients back to the hospitals. Although the resources available to effectively address the social determinants are limited, the first step in realizing their influence is to collect data. And that data collection requires asking about those determinants and including the appropriate ICD-10-CMS Z-code on the claim. Now imagine that hospital had a comprehensive pre-surgical assessment program for not only all surgeries that are part of TEAM, but every surgery. Not only would that evaluation have discovered her need for rehabilitation in a SNF, with the need for an inpatient admission order to be written pre-operatively giving her the ability to visit local SNFs to make an informed choice, but also allowing her social determinants to be recorded and incorporated into the hospital record and coded. In addition, Beatrice could have been connected with services available in her community to improve her overall health and wellbeing. For other patients, the pre-surgical assessment could allow determining which patients could be admitted as inpatient under the Medicare case-by-case exception. Physical therapy could assess the patient’s functional needs and anticipate need for treatment during and after surgery. Case management could ensure that the patient has a safe post-hospital recovery plan. The above scenario is doable for our potential pre-surgical patients. Identifying Social Determinants of Health on the Case Management assessment and incorporating them into our Case Management Care Plan is part of the Case Management Society of America’s (CMSA’s) Standards of Care required for all case managers. The pre-op screening with inclusion of a case manager on the team will prevent longer than necessary length of stays in hospital, or the need to change patients from ambulatory status to inpatient status after the surgery. This is not a new problem, patients with limited resources scheduled for planned hip arthroplasty have challenged case managers with a difficult discharge as long ago as 25 years. Twenty-five years ago, case managers struggling to find a safe discharge plan for the homeless total joint replacement patient, asked why the patient wasn’t identified as homeless at the pre-op appointment or the joint replacement class. As this situation is still playing out today despite states changes for hip arthroplasty, and coding changes, what is going wrong? Are we caring for diagnostic/Current Procedural Technology (CPT) codes, status, length of stay, and financial class, or are we caring for patients? CMS convenes nationwide experts who prescribe policy on how practitioners and health systems will deliver health care. They factor in many of the variables the experts on the ground request in the call for comments. Imagine the best-case scenario where the case manager and the physician advisor work together to not only optimize the medical care of the patient but also ensure that the patient’s social determinants are captured and coded, supporting the attributions to all the costs of their care and addressing the medical and social issues to truly improve the patient’s life. The detailed plan of care and subsequent notes of the case manager, facilitates correct coding and supports clinical documentation integrity (CDI) allowing patients to receive the post-acute care necessary for their recovery. Let’s not stop our efforts in care or coding when it is the right thing to do. Ronald Hirsch, MD, FACP, ACPA-C, CHRI Cynthia A Fleece RN, MBA, ACM, CHCQM-CM |