AAAs: Hub for Community Supports 

Addressing Social Determinants of Health

The case for effective identification and treatment of Malnutrition Risk

Presenter: Livleen Gill, MBA RDN LDN

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AGENDA

• Payment frameworks now target Social Determinants of

Health (SDOH)

• Current and changing health care landscape in Maryland

• Malnutrition’s impact on healthcare cost

• How do AAAs own the mission of being the community

hub – tools we will provide you to take charge

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Social Determinants of Health

• Definition of SDOH/HRSN

• SDOH screening and coding

• ICD-10 SDOH codes - Z55-z65

• Screening tools

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Federal Legislation

& Social Determinants of Health

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Chronic Care Act 2018

• Bipartisan Act that Congress passed On February 11, 2018

• New federal law advancing integrated, person-centered care

for Medicare & dually-eligible beneficiaries

• Medicare Advantage Plans and their role

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Key Medicare Advantage & SNP* Provisions

• Expands supplemental benefits & continues VBID

demonstration for chronically ill MA enrollees

• Permanently authorizes D-SNP, C-SNP, & I-SNP

• Promotes additional integrated care in D-SNPs

• Updates C-SNPs care management requirements &

condition list (e.g., HIV/AIDS, ESRD, & mental illness)

• Expands tele-health access

*SNP = Special Needs Plans

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Types of Covered Services

• Adult Day Services

• In-Home Support Services

• Support for Caregivers of Enrollees

• Home and Bathroom Safety Devices and Modifications

• Transportation

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Opportunities

• Focus on health beyond medical care

• Craft new partnerships to address SDOH

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Centers for Medicare and Medicaid

• HHS spends over $1 trillion a year on healthcare for the elderly and

vulnerable through Medicare and Medicaid

• In 2018 CMMI launched the Accountable Health Communities model to

address the human needs that may be impacting high utilizers of

healthcare

• Screenings for

Food insecurity

Domestic violence risk

Transportation

Housing and utility needs

Needs assessed : connect with community resources- pay for services

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Healthcare Influencers

& Social Determinants of Health

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American Medical Association

• Integrating training on SDOH in undergraduate medical school education

• Incorporating lifestyle medicine in medical school adopted by AMA house of

delegates (USC Greenville)

• Implemented training module for providers in addressing SDOH in their

practices (Steps Forward)

• Six common domains

• Economic stability

• Neighborhood

• Food

• Education

• Community/social support

• Healthcare system

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American Hospital Association

• Task force to improve access and delivery of care to address

SDOH (www.aha.org/ensuringaccess)

• Identified 3 ways for hospitals to engage

• Screening and information

• Navigation

• Alignment

• Community conversations Toolkit for hospitals

• CMS 10 question screening tool for SDOH across 5 key 

domains

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Maryland Healthcare

Current and changing health care landscape

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State of Maryland Landscape

• Medicaid Service delivery (MCOs)

• Medicaid community services

• Role of Maryland Access Point (MAP)

• Maryland Primary Care Program (MDPCP)

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Medicaid

Maryland Medicaid’s high cost areas 

(FY2017):

• Institutional LTSS (7.8% of enrollees)

Hospital

Home and community based LTSS

•

•

• In 2018, approx. 1.3 million people

enrolled in Medicaid (including CHIP)

• 81.5% of enrolled beneficiaries are in

Managed Care Organizations (MCOs)

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Other

Medicaid - Federal

Medicaid - State
Maryland Access Point (MAP)

• Single point of entry for access to services of state agencies

(https://md.getcare.com)

• 20 MAP sites in Maryland

• Funding sources are Title II and Title III

• Title III funding is for all persons 60 years and over and means testing is

prohibited

• MAP is the Aging and Disability Resource Program in Maryland. The ADRC initiative is sponsored by

the federal Administration for Community Living, the Centers for Medicare and Medicaid Services and

the Department of Veterans Affairs, and involves a national network operating in 54 states and

territories

• MAP is a centralized, single point of entry for anyone – individuals, concerned families or friends, or

professionals – to access aging and disability programs and services provided by state agencies and

private, public and community-based organizations

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Major MAP Funding Sources

Medicaid FFP

State, Local 

Funds, Grants, 

Contracts

Older Americans Act:

Title IIIB

I & A

Supportive Services:

Case Management

Chore Services

Personal Care

Homemaker
MDPCP

• Supports overall health care transformation process.

• Allows primary care providers to play an increased role

in prevention, management of chronic disease, and

preventing unnecessary hospital utilization.

• Voluntary program and open to all eligible primary care

providers.

• Practices enrolled in the program are supported by

Care Transformation (CTO) organizations and state

practice coaches.

• Practices and CTO are provided additional $$ per

beneficiary attributed in addition to fee for service

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$$
MDPCP

• Five Pillars of MDPCP

• Use of CRISP is

mandatory

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Beneficiary & 

Caregiver 

Experience

Comprehensivenes

s & Coordination

Care 

Management
Malnutrition

Impact on healthcare cost

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Malnutrition

What is Malnutrition?

• Malnutrition is the inadequate intake

of nutrients, particularly protein, over

time and may contribute to chronic

illness and acute disease or illness and

infection

Impact of Malnutrition

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• Frailty

• Disability

Loss of independence

Increased risk for falls

•

•

• Increased risk for infections

Delayed wound healing

Increased medical complications for other

other diseases

Hospital readmissions

•

•

•

• Increased length of stay

• Decreased effectiveness of medical

treatment
Prevalence of Malnutrition in Care Settings

• Acute care

• 20-50% of all patients are at risk for or are malnourished at the time of hospital admission (1)

• Only 7% of patients are typically diagnosed with malnutrition during their hospital stay (2)

• Post-Acute care

• 14- 51% of seniors are malnourished

• Community

• Estimated 6-30% of seniors are malnourished

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1 Barker LA, Gout BS, Crowe TC. Hospital malnutrition: Prevalence, identification, and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527. 

2 Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of hospital stays involving malnutrition, 2013. HCUP Statistical Brief #210. Rockville, MD: Agency for Healthcare Research and Quality. 

Available at: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb210-MalnutritionHospital-Stays-2013.pdf.
Local Prevalence of Malnutrition

Maryland Malnutrition Data

Maryland Statewide Malnutrition Data

Timeframe: Q2 2015- Q1 2018

County Specific Malnutrition Data

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Maryland County Data Malnutrition Data

Timeframe: Q2 2015- Q1 2018 

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Malnutrition Risk Factors

• Clinical- Diagnosed by physicians, NPs and PAs

• Social- Diagnosed by care managers, nurses, support care personnel

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The Role of the AAA

Own the mission of being the community hub – tools we will provide you to 

take charge

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Aging Network 

Overview 

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Screening for SDOH at MAC

Chronic Disease Assessment: 1) Do you have 2 or more chronic 

medical conditions? 2) Are you taking more than 5 medications? 3) Do you 

have difficulty managing your condition(s)? 

REFER TO LIVING WELL, COMMUNITY RESOURCES, HEALTHCARE

Falls Risk Assessment for patients over 65: 1) Have you fallen in the 

past year? 2) Do you feel unsteady when standing or walking? 3) Do you 

worry about falling? 

REFER TO FALLS PREVENTION WORKSHOPS, EXERCISE PROGRAMS, 

COMMUNITY RESOURCES

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Screening for SDOH at MAC

Depression Screen: Over the past two weeks, how often have 

you been bothered by any of the following problems? 1) Little 

interest or pleasure in doing things? 2) Feeling down, depressed or 

hopeless? 

REFER TO PEARLS, COMMUNITY RESOURCES, ATTEND SENIOR CENTERS/

CONGREGATE MEALS

Malnutrition: 1) Have you recently lost weight without trying? 2) If yes, 

how much weight have you lost? (MST – Malnutrition Screening Tool)

REFER TO STEPPING UP YOUR NUTRITION, FALLS PREVENTION, LIVING 

WELL, MEALS PROGRAMS, EXERCISE PROGRAMS AS APPROPRIATE. IF 

FOOD INSECURE, FOOD PANTRIES AND OTHER RESOURCES.

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Multi-Disciplinary Approach

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MAP

Type of intervention Action 

Screening • Malnutrition Screen

• Falls Screen

• Depression Screen

Client Support Care Plan • Enroll/refer to Nutrition, HP and/or SHIP

• Transportation to healthcare appointments and referral sites

Address Root Cause • Program Eligibility

• Refer to Behavioral Health, caregiver support, Physician, CHW

• Grocery program, pet food, call reassurance, etc

Communicate Progress • Track Referrals

• Incorporate client Options Counseling goals

• Assist with hospital messages and progress
Multi-Disciplinary Approach

Nutrition Program 

Type of Intervention Action 

Screening • Malnutrition Screen

• Food Insecurity Priority Screen

Client Support Care Plan • Person- centered service/meal plan

• Provide Social Interaction

• Nutrition education

Address Root Cause • Nutritionally balanced food

• Social isolation

Hydration

Manage chronic conditions

•

•

Communicate Progress • Track Participation

• Assist with hospital messages and progress

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Multi-Disciplinary Approach

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Health Promotion 

Type of Intervention Action

Screening • Varies based on program and staff certifications

Client Support Plan •Exercise

Strength

Nutrition

Chronic Disease Management

•

•

•

Address Root Cause (s) • Social isolation

• Manage chronic conditions

• Falls risk

Communicate Progress • Track Referrals

• Share Client goals with healthcare team

• Assist with hospital messages and progress
Multi-Disciplinary Approach

SHIP

Type of Intervention Action

Screening • Benefits Check-up

Client Support Care • Identify & assist with medical insurance gaps

Addressing Root Cause (s) • Address gaps in insurance coverage (income)

Communicate Progress • Regular follow-up for high risk clients

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Case Study

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Case Study

• B.B. is an 85 year old woman who was referred to our

practice in early February 2018. She presented socially well

and was always well groomed.

• She had 42 ER visits to the local hospital in 2018

• She had two mini fires in her apartment

• She had not filled medications at the pharmacy since late

2017

• Calls would average between 2-8 times in a given day

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Case Study

• Our practice provided telephonic touch points, office visits,

home visits, information to EMS, hospital SW, contacted family

• We provided food items, supplements

Finally reported to APS as things kept escalating after 3 months

APS kept an eye on her but could not really do much

•

•

• In January 2019 was delirious and admitted to hospital psych

unit

• APS filed for temporary guardianship

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SDOH & ICD-10 Codes 

SDOH Domains ICD-10 codes for SDOH

Living Situation 

including housing 

and utilities

Z59 – Problems related to housing and economic circumstances

Z60 – Problems related to social environment 

• Z60.2 – Problems related to living alone

Food Z59 – Problems related to housing and economic circumstances

• Z59.4 – Lack of adequate food and safe drinking water

Safety Z60 Problems related to social environment

Financial Strain Z59 – Problems related to housing and economic circumstances

Employment Z56 – Problems related to employment and unemployment

Family and 

Community Support

Z63 – Other problems related to primary support group, including family circumstances

Z60 – Problems related to social environment

Education Z55 – Problems related to education and literacy

Mental Health Z64 – Problems related to certain psychosocial circumstances

Z65 – Problems related to other psychosocial circumstances

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Case Study

• Ideal Pathway for B.B.

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Next Steps: Tools to Take Charge

• Malnutrition Toolkit draft one week before in person meeting:

• Rationale for community-based interventions

• Community-based Malnutrition care pathway

• Professional role delineation

• Template presentations

Billing codes to match interventions

In person meetings to solicit feedback on feasibility of draft

•

•

toolkit (February)incorporate feedback in toolkit (March)

• Web meeting to disseminate toolkit (March/April)

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Thank you!

Livleen Gill, MBA RDN LDN

CEO of Bethesda NEWtrition and Wellness Solutions

Camalier Building

10215 Fernwood Road, Suite 630

Bethesda, MD 20817

Tel: (240) 449-3094

Fax: (240) 489-4415

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