This infographic describes the journey that social determinants of health (SDOH) data takes from the individual through the health system to data reporting as ICD-10-CM Z codes. It discusses data collection, documentation, coding, and reporting. It contains resources to help implement programs to collect and report SDOH data in a manner that can lead to better health outcomes for individuals.
For more on Z Codes, read the data highlight: Utilization of Z Codes for Social Determinants of Health among a Sample of Medicare Advantage Enrollees, 2017 and 2019 (PDF).
A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool: Promising Practices and Key Insights (PDF)
This document describes the health-related social needs (HRSN) screening tool from the Accountable Health Communities Model, which works to identify HRSNs, or individual-level, adverse social conditions that negatively affect an individual’s health or health care. By identifying and addressing HRSNs, health care and social service providers can improve an individual’s health and reduce health care spending. This guide shares promising practices to help providers adopt HRSN screening.
Resources on CMS’s Financial Alignment Initiative (FAI) for Medicare-Medicaid Enrollees
The Financial Alignment Initiative is designed to provide individuals dually enrolled for Medicare and Medicaid with a better care experience and to better align the financial incentives of the Medicare and Medicaid programs. Through the Initiative, CMS partners with states to test two new models for their effectiveness in accomplishing these goals. Learn more on the Financial Alignment Initiative for Medicare-Medicaid Enrollees page.
Read this issue brief (PDF) to learn about the approaches FAI states, managed care plans, and care coordination entities are taking across the demonstrations to address a wide range of enrollees’ social determinants of health.
Primary care practice teams can help reduce disparities in care for chronic kidney disease (CKD). This educational guide is intended to foster the development of primary care practice teams in order to enhance care for vulnerable patients who are at risk of CKD or who have CKD and are at risk of progression of disease.
The Resources Inventory is a catalog of diabetes prevention resources tailored to various audiences, including people from racial and ethnic minorities, LGBTQ communities, people with disabilities, and people with limited English proficiency.
The Provider Directory is designed to facilitate diabetes treatment for primary care teams, particularly providers working with people on Medicare and populations who experience a higher prevalence of type 2 diabetes and its complications.
The resources in this inventory include guidance on how to increase physical accessibility of medical services, tools to assess your practice or facility's accessibility, and tips and training materials to support efforts to reduce barriers and improve quality of care for individuals with disabilities.
Focused quality improvement efforts should target populations at risk for disparities. Explore this guide for resources and concepts key to addressing disparities and improving health care quality throughout your organization.
Learn how to identify, prioritize, and take action on health disparities by championing the Disparities Impact Statement in your organization. Participants receive personalized technical assistance focused on strengthening their quality improvement program through a series of consultations from subject matter experts.
Building an Organizational Response to Health Disparities: Five Pioneers from the Field
Learn how five organizations have made a business case for addressing disparities in health care quality and access. Organizations such as hospitals, health plans, health systems, and others may see their own motivations and challenges reflected in these examples. These case studies increase the evidence base for health organizations in support of building a business case to reduce health disparities.
A Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities, People with Disabilities and Sexual and Gender Minorities (PDF)
The purpose of this toolkit is to enable organizations to implement the National Culturally and Linguistically Appropriate Services (CLAS) Standards and improve health equity. It is organized according to the enhanced National CLAS Standards, and provides practical tools and examples of CLAS, in addition to efforts to implement the National CLAS Standards that can be adapted for use by health care organizations. It is intended for organizations that have already decided to pursue CLAS, improve equity, and eliminate health care disparities.
Effective communication is critical to ensuring understanding, empowering patients, and providing high-quality care. A language access plan can help ensure that an organization provides high-quality and appropriate language services. This guide identifies ways that providers can assess their programs and develop language access plans to ensure persons with limited English proficiency have meaningful access to their programs.
Across the country, health care organizations are using innovative approaches to provide language assistance services to individuals with limited English proficiency. This resource discusses approaches used by these organizations to provide language assistance services to persons with limited English proficiency based on the findings of case studies conducted with a variety of health care organizations.
This guide provides an overview of key issues related to readmissions for racially and ethnically diverse Medicare enrollees, as well as useful resources for hospital leaders to take action to address readmission.
This targeted intervention focuses on the HEDIS® measure of colorectal cancer screening, stratified by race and ethnicity, to demonstrate how to lower the costs and improve the quality of care for vulnerable Medicare, Medicaid, and dual-eligible enrollees. This approach will help you to prioritize your actions.