CMO Corner: Lawrence Magras, MD, MBA, FHM, FAAPL

What Are Social Determinants of Health?

The World Health Organization (WHO) defines social determinants of health (SDOH) as the structural determinants and “conditions in which people are born, grow, live, work and age.”1 Social and environmental factors contribute 20% or more to premature death in the U.S.2 SDOH are among the most influential factors that determine the health outcomes of HUSKY Health members. The healthcare system plays a vital role in addressing SDOH to improve patient outcomes. Collecting data at the patient level is essential to supporting the role of healthcare organizations. . . read more

Recent data shows that:

  • Over 14% (or one of every seven people) of the U.S. population is food insecure (lacking reliable access to a sufficient quantity of affordable, nutritious food).
  • 8.3 million renters were classified as having worst-case needs or as having experienced housing instability in 2015 according to the U.S. Department of Housing and Urban Development (HUD).
  • Individuals who are housing-unstable are more likely to visit an emergency room, have longer hospital stays once admitted, and have higher likelihoods of readmission.

Why Are SDOH’s Important?

The National Quality Forum examined the impact of social determinants on health outcomes measures.3 These significant barriers impact patients’ ability to effectively manage their health and engage in care. Identifying and addressing these barriers can improve access to vital services and ultimately improve health outcomes. The healthcare team plays a major role in addressing SDOH. This can be done by implementing tools that assess SDOH and creating standards for inputting and extracting social needs data from electronic health records.

As part of your assessment, consider screening your patients by asking the following questions:

  • In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough money for food?
  • Are you worried or concerned that you may NOT have a place to live?

HUSKY Health is committed to addressing the SDOH needs of our members and their families in partnership with their providers. HUSKY Health offers an Intensive Care Management (ICM) program that can assist you with coordinating care for your patients once you have identified SDOH needs. Licensed Care Managers will work directly with you to share resources, coordinate care, and assist with making specialist referrals. To refer patients to the ICM program, providers may call 1.800.440.5071 and select the prompt for Intensive Care Management, or complete the ICM Referral Form. For additional information on the ICM program, please click here.

Coding Is Important!

Ensuring that the proper ICD-10 codes are captured on a claim will allow individuals who may need assistance to be identified for research and relative risk categorization, as well as be connected with the appropriate community resources.

Description ICD-10 Codes
Food insecurity Z593.4
Housing instability Z59.0
Domestic violence risk Z63.0
Problems related to social environment Z60.0, Z60.2, Z60.3, Z60.4, Z60.5, Z60.8, Z60.9
Problems with primary support group including family circumstances Z63.0, Z63.1, Z63.31, Z63.32, Z63.4, Z63.5, Z63.6, Z63.71, Z63.72, Z63.79, Z63.8, Z63.9
Problems related to psychosocial circumstances Z64.0, Z64.1, Z64.4, Z65.0, Z65.1, Z65.2, Z65.3, Z65.4, Z65.5, Z65.8, Z65.9
Problems related to education and literacy Z55.0, Z55.1, Z55.2, Z55.3, Z55.4, Z55.8, Z55.9
Problems related to employment and unemployment Z56.0, Z56.1, Z56.2, Z56.3, Z56.4, Z56.5, Z56.6, Z56.81, Z56.82, Z56.89, Z56.9
Occupational exposure risk Z57.0, Z57.1, Z57.2, Z57.31, Z57.39, Z57.4, Z57.5, Z57.6, Z57.7, Z57.8, Z57.9
Economic barriers Z59.1, Z59.2, Z59.3, Z59.5, Z59.6, Z59.7, Z59.8, Z59.9
Problems related to upbringing (Adverse Childhood Experiences [ACE]) Z62.0, Z62.1, Z62.21, Z62.22, Z62.29, Z62.3, Z62.6, Z62.810, Z62.811, Z62.812, Z62.819, Z62.820, Z62.821, Z62.822, Z62.890, Z62.891, Z62.898, Z62.9





Social Determinants of Health Summit

On April 19, 2018, Community Health Network of Connecticut, Inc. (CHNCT) and the HUSKY Health program hosted the first annual Social Determinants of Health Summit. This one-day event brought together leaders and changemakers from non-profit organizations, corporations, health and medical organizations, and government agencies, all of whom were eager to engage in thought-provoking conversation about social determinants of health (SDOH). . . read more

The World Health Organization defines SDOH as the structural determinants and “conditions in which people are born, grow, work and age.”1 But what does that really mean to us? Should we, as healthcare professionals, be focusing on living conditions, environmental factors, and socioeconomic status? As Don Hall, M.P.H, Principal of DeltaSigma, LLC, and moderator of the Social Determinants of Health Summit, so powerfully phrased it: social determinants of health have “nothing to do with healthcare and everything to do with healthcare.” Certainly, something like zip code is not directly linked with healthcare; however, zip code can determine a multitude of things that do affect healthcare: are there enough providers in the area? Is there public transportation available? Is it safe to walk or ride a bicycle to an appointment?

During her presentation at the summit, Claire Pomeroy, MD, MBA, President of the Albert and Mary Lasker Foundation said, “The challenge is to create the social and physical environments that promote good health for all.” When assessing a patient, no provider is expected to spread cement, filling an entire zip code with safe sidewalks, but what can be done is to learn from the patient about those unsafe conditions and then offer resources to assist, if available. Robert Zavoski, MD, M.P.H., Medical Director of the Connecticut Department of Social Services noted that, “we’re trying to bend patients to their care and not the care to the patient’s needs” and that should change; health equity versus health equality.

The 2nd annual Social Determinants of Health Summit will be held in the Spring of 2019. It is the goal of CHNCT and HUSKY Health to continue this important conversation about SDOH, to dive deeper into the concepts of how we can assist instead of being absorbed by the question of why these SDOH exist at all. It’s time to focus further on the “how” and not the “why.”



Essentials of Psychiatry in Primary Care – September 15, 2018

Essentials of Psychiatry in Primary Care is an all-day, integrated behavioral health program intended to educate Primary Care Providers (PCPs) in the early identification, accurate diagnosis, effective treatment, and appropriate referral of patients with psychiatric disorders. This conference is being offered to PCPs enrolled in the Connecticut Medical Assistance Program (CMAP) at no cost. We have worked to ensure a varied program for professional development and networking opportunities. CME credits will be awarded based on the extent of the provider’s participation in the activity. To learn more and to register for this conference, go to

Addressing Social Determinants of Health in Members to Improve Outcomes

The Community Health Network of Connecticut, Inc. (CHNCT) Intensive Care Management (ICM) program is a voluntary program, available to all HUSKY Health members. The program is designed to assist members living with chronic conditions, including those with asthma, diabetes, and perinatal complications. The goals of the ICM program are to empower members to participate in their healthcare and to identify and address barriers to care which can hinder effective management of their disease process. . . read more

The ICM care manager works with members by conducting a systematic assessment to determine factors affecting the health of members. A functional assessment is completed to screen and assess the member’s concerns about their basic needs and self-care. It includes an assessment for social determinants of health (SDOH) to identify community resource needs such as: income, housing, food insecurity, employment, and health literacy as these factors can have a direct correlation to health outcomes. It is understood that basic needs must be met before members are able to focus on their health. For example, food insecurity may affect the nutritional status of an expectant mother and baby both during and after pregnancy.

The ICM care manager assesses for, and addresses any gaps in care, such as: date of last physical exam, and verifying if immunizations are up-to-date to promote a healthy lifestyle for members.

The ICM care manager’s role involves coordination of care, by collaborating with community organizations and providers to address SDOH in order to facilitate improvements in the member’s health outcomes. CHNCT uses a multi-disciplinary approach in the care management program by collaborating with Registered Dieticians, Certified Diabetes Educators, Lactation Specialists, Pharmacists, and Community Health Workers. The care management team encourages members to work with local agencies and landlords to address environmental concerns such as mold or rodent droppings in the home. The ICM team also works with members on ways to minimize exposure to smoking by household members or people who live in the same apartment building.

Members are referred to smoking cessation programs, assisted with Supplemental Nutrition Assistance Program (SNAP) applications and referrals for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Nurturing Families, and Text4baby as well as food banks and mobile food truck sites that service their community.

In addition, the ICM care manager outreaches to members within two days after discharge from the hospital to assess for potential barriers in following the discharge plan, such as: coordinating transportation to medical appointments, reviewing the discharge instructions and list of medications, and reinforcing the importance of follow-up appointments with their providers.

There are a number of ways that providers can refer their members to CHNCT’s ICM program:

  • Submit a referral online by going to, clicking on “For Providers,” then select “Repors and Resources,” “Provider Forms,” followed by “ICM Referral Form.”
  • Call HUSKY Health Provider Engagement Services at 1.800.440.5071 x2024
  • Send a fax to 1.866.361.7242