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Social Determinants Updates

April 3 to April 17, 2020

Welcome to Aligning for Health’s Social Determinants Updates newsletter.

Hoping you are all safe and well during these uncertain times.

In this newsletter you'll find updates on how the health care system is responding to health and social needs during the current public health emergency, as well as other notable links to research, data, and news related to social determinants; and upcoming virtual events and opportunities.

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Member News

Modern Healthcare: (4/16) – AFH member American Hospital Association, the American Medical Association and the American Nurses Association send a letter to HHS urging the Administration to collect more information about what is causing high rates of COVID-19 infection and death among African Americans and other people of color.

Centene: (4/13) – AFH member Centene announced new community investments to address social determinants of health focused on combatting hunger, improving connectivity and providing key health and educational products to those in need.

HIT Consultant: (4/9) – As the healthcare industry better understands the effects of loneliness and social isolation in the Medicare population, payers like AFH member Humana and providers are exploring initiatives to address social isolation among members and patients through analytics, partnering with community organizations, and supplemental benefits.

AHA: (4/7) – AFH member American Hospital Association published a case study highlighting an example of how one of their members, SoHum Health is working to address social determinants of health to save the lives of seniors, using a network of clinical professionals, social workers, caregivers and volunteers to cater to the needs of area seniors aging in place.

Health Affairs: (April) – This report reviewed nine new technology platforms that work to facilitate referrals from health care organizations to social service organizations, including AFH members Signify and UniteUs.

Social Determinants Accelerator Act

AAMC(4/10) – The Association of Medical Colleges responded to an inquiry to StakeHolders from the Senate Finance Committee about solutions to improve maternal health and recommended that the Social Determinants Accelerator Act be passed to support planning grants for communities. 

Brookings Institute: (4/6) – The Brookings Institute released a report on budgeting to promote social objections, recommending the passage of the Social Determinants Accelerator Act.
American Hospital Association(4/3)
– The American Hospital Association recommended passing the Social Determinants Accelerator Act to address social needs for mothers.

AFH Resources on Social Determinants

The current COVID-19 public health crisis has affected every community, but has a significant impact on vulnerable populations. It has affected our health and mental health, and has hindered access to necessary supports and resources.

Aligning for Health has put together a set of resource documents that include links to COVID-19 data and GIS tools, resource directories, and guidance from the federal and state governments. We will continue to update these resources and hope they will be helpful.

Resource Roundup and Medicaid Flexibilities


NCQA: (4/17) – NCQA wrote an article about how they are brainstorming ways to address social determinants of health in response to COVID-19, highlighting their proposal to create standards for Medicaid managed-care plans that would aim to improve access and outcomes by encouraging plans to focus on social determinants.

Health Affairs: (4/16) – Years of budget cuts and underinvestment in public health have made it challenging for local health departments to maintain these foundational capabilities to slow the epidemic and minimize its impact on communities, let alone the surge capacity of COVID-19.

Experien(4/16) –This article discusses how health plans can prepare to close gaps in care when COVID-19 subsides, including using tools to identify and understand members' social determinants of health barriers and factoring those into overall plans. 

Health Affairs: (4/16) – In the COVID-19 pandemic, there is an urgent need to target resources to where they are most needed. Health care organizations can play a significant role in lessening the adverse impacts of the virus on vulnerable communities.

BenefitsPro: (4/15) –Beyond concerns about whether their workers will contract COVID-19 and what can be done to protect them, there’s also a growing focus on the well-being of employees as they struggle with financial and mental stress and the social determinants of health.

AJMC: (4/15) – As COVID-19 exposes and exacerbates social determinants of health in at-risk communities, services such as clinical trials and personalized care can provide effective interventions for employers in providing access to vital services.

Health Affairs: (4/14) – As COVID-19 cases have spread across the country, people are turning to community-based social service organizations in ever-higher numbers for help with food, rent and utility assistance, making the funding for health and social services integration even more crucial.

Patient Engagement HIT: (4/14) – Leading physician groups are calling on the Administration to collect racial and sociodemographic data about individuals impacted by COVID-19 in order to understand and address health disparities.

Health Payer Intelligence: (4/14) – Medicare Advantage plans like Cigna and SCAN Health Plan’s Medicare Advantage programs are focused on decreasing senior social isolation during the coronavirus pandemic through new programs and funding, relying on volunteers and community partnerships.

AMA: (4/14) – Leading voices of national physician bodies came together in a recent panel hosted by the AMA to discuss COVID-19 and how it disproportionately affects minority communities

Health Affairs: (4/14) – Many have recently called for improved collection and reporting of COVID-19 sociodemographic data, including data at the national, state, county, city, neighborhood, and health system levels.

NASHP: (4/13) – An analysis by NASHP of state public health websites found that 25 states and Washington, DC are reporting COVID-19 data by race and/or ethnicity.

Patient Engagement HIT: (4/13) – A new data visualization tool out of Rensselaer Polytechnic Institute will demonstrate how the social determinants of health are affecting COVID-19 risk and outcomes across disparate communities nationwide and throughout individual counties in New York.

New York Times: (4/13) – The coronavirus pandemic could sharpen the health risks of loneliness as community resources that facilitate social interaction for seniors are shut down.

Health IT Analytics: (4/13) – The UC San Francisco School of Medicine Dean’s Office of Population Health and Health Equity has launched a new interactive mapping website that curates publicly available community data, including COVID-19 cases and deaths in California.

The Center Square: (4/10) – Louisiana announced the launch of a task force to study COVID-19-related health disparities and ensure all communities have accurate and timely information about safety and prevention.

Becker’s Hospital Review: (4/10) – The Association of American Medical Colleges has asked for the development of a national COVID-19 data collection system to address race and ethnicity health disparities as well as other social determinants of health.

Austin Monitor: (4/7) – Senior citizens in Central Texas are finding their access to food limited and their social isolation increased. Services like Meals on Wheels and food banks have been working to fill the gap, but are limited by social distancing rules and a constricted food supply chain.

PEW Charitable Trusts: (4/6) – The COVID-19 pandemic shows that responses to public health challenges require public policy solutions that need to look across social sectors.

Milwaukee Independent: (4/3) – Milwaukee city officials revealed that Milwaukee’s African American community is disproportionately affected by the COVID-19, highlighting existing social determinants of health and health disparities that must be addressed during and after the pandemic.

Children’s Hospitals: (4/3) – This report outlines how children’s hospitals are implementing social needs screening, highlighting the need for community resource connections, provides examples of screener tools being utilized, and offer questions to consider when implementing a new strategy to screen.

NIHCM(April) – NICHM has compiled links to information on COVID-19 and vulnerable populations. 

New Research and Reports

Healio: (4/15) – According to data presented at the virtual American College of Cardiology Scientific Session, food, housing and financial insecurity greatly increased the odds of cardiovascular disease based on analysis of more than 400,000 participants from 17 states.

Patient Engagement HIT: (4/13) – A qualitative study of CMS Accountable Health Communities providers shows a discordance in risk perception when forging a community health partnership, according to research from the Center for Health Systems Effectiveness.

Health Payer Intelligence: (4/13) – A new study in Health Affairs examines how California’s whole person care 1115 Medicaid demonstration waiver illustrates the challenges Medicaid programs face in providing care coordination for Medicaid beneficiaries and offers insight on how to overcome these challenges.

Modern Healthcare: (4/6) – When mental health providers and hospitals partner with local agencies focused on helping older adults stay independent, Medicare spending decreases and nursing home use falls, according to a new study in Health Affairs.

Healio: (4/6) – Research presented at the American College of Cardiology Scientific Session found that age-adjusted deaths from hypertension-related cardiovascular disease increased from 2007 to 2017, which an increase in the rural South that can be linked to obesity, diabetes, and disparities in social determinants of health.

Brookings Institute: (4/6) – The Brookings Institute released a report on budgeting to promote social objections, which is a primer on braiding and blending describing the many ways government at different levels actually does permit the braiding and blending of funds to pursue broad objectives.

Health Affairs: (April) –Housing Prescriptions as Health Care is a randomized controlled trial investigating the impact on physical and mental health of integrating priority placement in affordable housing and the provision of services compared to the standard of care. The study suggests that a population-specific model that integrates health, housing, legal and social services can improve health-related outcomes at the household level.

Health Affairs: (April) – Results from a study evaluating Project Nurture, an innovative model that integrates maternity care, substance use treatment, and social service coordination for Medicaid beneficiaries in Portland, Oregon , suggest that models based in a clinical setting that engage the human sector may improve overall outcomes, even though the difficulty in shared savings across sectors presents challenges to sustainability.

Health Affairs: (April) – Through qualitative interviews, this study examined perspectives of housing sector stakeholders on the opportunities and obstacles of including health-related criteria in Low-Income Housing Tax Credit funding decisions.

Health Affairs: (April) – This article proposes an innovative methodological approach called cash benchmarking, which can help determine when health care and human services integration is most useful.

Health Affairs: (April) – This article provides a legal and policy review to identify potential funding streams specifically for Accountable Communities for Health infrastructure activities, capturing insights from leaders at 22 health and human services organizations in Oregon who were involved in the CMS initiative in 2019.

Trust for America’s Health: (April) – TFAH released a report on the impact of chronic underfunding on America’s public health system, highlighting trends, risks and recommendations for FY 2020.

Health Affairs: (April) – This report provides an overview of collaborations, partnerships and other integration efforts between health care and social services organizations, highlighting the need for increased societal investments in resources to address social needs to create integrative initiatives that will yield the desired individual and population-level impacts.

Building Health Places: (3/31) – Build Healthy Places Network, Prosperity Now, and Financial Health Network released a research brief on alignment across the community development, health and financial well-being sectors, presenting examples of existing alignment across sectors, opportunities, challenges, and recommendations for increased collaboration.

Health Affairs: (April) – This article describes four interconnected initiatives that the North Carolina Department of Health and Human Services has implemented to integrate medical and nonmedical drivers of health at scale.

SDoH in the News

Health IT Analytics: (4/15) – The Office of the National Coordinator (ONC) is working to standardize the collection of social determinants of health data as part of the Precision Medicine Initiative to help advance precision medicine and inform new treatments.

Mathematica: (4/9) – After winning the Agency for Healthcare Research and Quality challenge with their Community Connector tool, the Mathematica team explained their process behind creating the tool and their plans for expanding the use of the tool in the future.

Healthcare Finance: (4/9) – Brian Dixon, the director of the Public Health Informatics for Regenstrief Institute and Professor at Indiana University Fairbanks School of Public Health, shares the success of integration of social determinants into health information exchange networks in Indiana.

JAMA: (4/3) –JN Learning featured a podcast with Dr. Sandro Galea discussing his book “The Role of Physicians in Addressing Social Determinants of Health.”

EHR Intelligence: (4/3) – Addressing social determinants requires integration of this information into the EHR, otherwise providers will not be able to use this data for clinical decision-making.

Milbank Quarterly: (3/31) – The Milbank Quarterly has issued a post from North Carolina officials about their work to improve population health by aligning measures around upstream health drivers.

NEJM Article Preview: (May-June) – The NEJM interviewed members of the NEJM Catalyst Insights Council on the challenges of scaling SDOH programs, but a lack of consensus on what to focus on first may hinder early success.

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