CMS recognizes the critical role that non-clinical factors such as food and housing security, loneliness and educational achievement play in determining a patient’s ability to access care and adhere to treatment—which ultimately determines outcomes.  CMS is encouraging providers to take advantage of “Z-codes” in ICD-10.  By using these codes as well as greater scrutiny of Medicare and Medicaid data, CMS is hoping to bring more evidence-based resources to the daunting task of managing vulnerable populations.

CMS also points providers to other resources including the Accountable Health Communities (AHC) social needs screening tool, the PREPARE tool from the National Association of Community Health Centers, or the Health Leads Screening Toolkit to better understand their patient’s challenges.

 

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