MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-mcc/ and changes regularly. See the Directory of published versions

MCC Care Plan SDOH Guidance

MCC Care Plan Approach to Social Determinants of Health (SDOH) Data Representation

The United States Core Data for Interoperability (USCDI), published by the Office of the National Coordinator for Health Information Technology (ONC) includes SDoH data elements. SDOH are the conditions in which people live, learn, work, and play. Social risks are adverse SDoH associated with poor health (e.g., food insecurity, lack of access to health care, lack of transportation, housing instability, etc.). Social needs are the social risks an individual patient feels are most pressing and need to be addressed. Interdisciplinary Care Planning and Care Coordination have long acknowledged the SDOH because of their effects on health risks and outcomes. The Gravity Project has led a national public collaborative to develop consensus-based data standards to improve use and sharing of SDOH data. Their growing and evolving body of work includes defining use cases, suggesting/defining workflows and developing value sets in order to encourage and facilitate the capture of data in a structured and standardized way to get the data flowing into EHRs and other systems. The HL7 US Core Implementation Guide is the method by which USCDI Data Element are standardized for exchanging the data using FHIR. Given that the MCC IG reuses and constrains US Core Profiles for use in a FHIR Care Plan, by default, the IG inherits the US Core Screening and Assessment Guidance with special attention to Codes for Problems/HealthConcerns, Goals, Service Requests, and Procedures.

The MCC eCare Plan and SDOH Activities

The differences between US Core Profiles and their corresponding MCC profiles are the constraining or emphasis on FHIR elements or extensions used to represent linkages between profiles to align with the care planning process of assessing to identify conditions or health concerns and associated goals, planning and executing interventions/activities, and tracking outcomes. The description and supporting diagram shows the Care Planning process with an SDOH view and states the profiles used to represent the SDOH concepts.

• SDOH Assessment: SDOH Assessments represent the recording of SDOH assessment screening tools and other questionnaires as well as individual clinical observations. These assessments are represented by the MCC Observation SDOH profile derived from the US Core Observation Screening Assessment Profile
• SDOH Problems/Health Concerns/Social risks or needs: Identifying a social risk (for example, homelessness) is represented by the MCC Chronic Condition and Health Concern Profile derived from US Core Condition Problems and Health Concerns Profile.
• SDOH Goals: Identifying and defining a future desired condition or change in condition related to a social need (for example, Has adequate quality meals and snacks) is represented by the MCC Goal derived from the US Core Goal.
• SDOH Interventions: Services offered to a patient to address identified SDoH concerns/priorities, or social needs, (for example, referral to transportation support programs) are represented by the MCC Service Request profile derived from US Core ServiceRequest Profile. In addition, the MCC Care Plan Procedure derived from US Core Procedure Profile can be used to record a completed service or intervention.

SDOH eCare Planning Activities

Codes for MCC Problems/HealthConcerns, Goals, Service Requests, and Procedures

The Gravity project is developing granular value sets that contain concepts for very specific SDOH situations. These small, specific value sets are being developed overtime to support workflow and consistent data collection. Gravity has grouped these small value sets into broadly defined sets for use across other uses case. Both US Core and the MCC IG leverage these value sets so that SDOH concepts that have been collected may be queried for and aggregated. As new Gravity value sets are developed, they will be added to the appropriate, broadly defined grouped value set. These value sets may be used with problems/health concerns, goals, procedures, and service requests:

• Social Determinants of Health Condition
• Social Determinants of Health Procedures
• Social Determinants of Health Goals
• Social Determinants of Health Service Requests

MCC and US Core use these broadly defined value sets that contain concepts that are used across many use cases including SDOH. The Figure below illustrates how the Gravity value sets are grouped for use in the MCC Chronic Condition Problems and Health Concerns Profile and how the grouped value set is compatible with the US Core Problem code valueset. When recording SDOH data MCC Profiles and servers SHOULD use the SDOH value sets listed above.

Example of SDOH Grouping Value set available for use in MCC Chronic Condition Profile