Social Determinants Updates |
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October 28 to November 11, 2022
Welcome to Aligning for Health's bi-weekly Social Determinants Updates newsletter.
To add news or events to this newsletter, email info@aligningforhealth.org.
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Member News
Department of Veterans Service: Georgia Department of Veterans Service and Unite Us Team Up to Expand Coordinated Care Network, Streamline Access to Services (11/9) – The Georgia Department of Veterans Service (GDVS), the state agency dedicated to advising, counseling, and assisting veterans and their families in receiving their rightful benefits, partnered with Unite Us to help meet the unmet needs of Georgia’s veteran population through a coordinated care network called Unite Georgia. The Unite Georgia program will initially be available through the 54 GDVS veterans field service offices located across the state.
Blue Shield of California: How Health Plans Can Facilitate Data Use to Address Social Needs and SDOH (11/3) – Blue Shield of California, a health plan of the Blue Cross Blue Shield Association, guided a new white paper in collaboration with Golden State Health Policy and BluePath Health on how health plans can facilitate data use to address SDOH and social needs. The white paper outlines the ways in which health plans can leverage their resources to support the effective collection, sharing, and use of SDOH and social needs data.
CareSource: CareSource Funds Expansion of Housing Equity Pilot Program (11/1) – CareSource is dedicating $200,000 to expand the Healthy Beginnings at Home pilot program to Dayton and Montgomery County. Healthy Beginnings at Home provides housing assistance and stabilization services to pregnant women experiencing housing insecurity while also gathering scientific data on the correlation between stable housing and improved birth outcomes.
Journal of Primary Care & Community Health: Calling Your Aunt Bertha for Social Assets: Family Medicine and Social Determinants of Health (10/27) - Primary care practices are increasingly expected by payers and policy makers to assess patients’ social needs. Resource referral platforms provide physicians with information and referral systems for community resources. findhelp (previously Aunt Bertha) is one commonly used platform to do this, and the American Academy of Family Physicians (AAFP) Neighborhood Navigator (NN) tool allows physicians and laypeople to search for resources using this platform. This study sought to describe what users were searching for and to identify patterns to inform resource allocation.
Vizient: Pilot Program to Help Hospitals Bolster Retention by Identifying, Addressing Employee Social Needs (10/25) – Vizient lead data scientists are applying the capabilities of the Vizient Vulnerability Index to health system member workforces as part of a pilot program that will examine how social drivers of health affect a hospital’s employee population. The goal of the pilot is to help members identify the specific socioeconomic challenges their employees face so they can pinpoint the most effective ways to address their needs.
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Join Aligning for Health and RISE for the Social Determinants of Health Policy Forum
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In cooperation with Aligning for Health, RISE is bringing together policymakers, policy experts, and practitioners from across the health and social services sectors to explore the current and future state of social determinants of health policy. Learn from, engage with, and network with government leaders on federal efforts to increase coordination and impact of programs and services that address health and social needs. In the heart of Capitol Hill, join the only forum gathering state and local governments, leading payers, providers, community-based organizations, and health networks providing insights into innovative programs, models, and best practices to advance whole-person health. Walk away with a better understanding of policies and programs that advance and support data sharing, collaboration, financing, accountability, and equity.
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Legislative Updates
House Committee on Rules: Ending Hunger in America Draft Report Markup (11/9) – The House Committee on Rules announced it will hold a markup on November 14 to consider a draft report to the House of a compilation of witness testimony, items for the record and letters of support from the Ending Hunger in America initiative and corresponding events.
The Hill: Lawmakers push to end maternal health crisis (11/4) – Lawmakers continue to push for increased protections for pregnant people of color in the hopes of passing legislation before the end of the 117th
Congress. The Black Maternal Health Caucus has been leading legislative talks. Rep. Underwood (D-IL), a lead sponsor of the Momnibus legislative package to address maternal health disparities and co-chair of the Black Maternal Health Caucus, said the caucus is happy with the progress made so far.
To view a full list of the legislation we are tracking around social determinants of health, health equity/disparities, and maternal health, click here.
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Administration Updates
JAMA Health Forum: New Federal Efforts to Address Food and Nutrition Insecurity (11/10) – In this article, officials from HHS and US Department of Agriculture (USDA) outline federal efforts to address food and nutrition insecurity, including initiatives outlined in the national strategy released at the White House Conference on Hunger, Nutrition, and Health. This strategy offers a promising roadmap to address this issue, but cross-sector research and partnerships are necessary to implement it effectively to improve access to nutritious food and end hunger.
CMS: The Path Forward – Improving Data to Advance Health Equity Solutions (11/10) – The CMS Office of Minority Health published a blog post outlining a plan to tackle health equity data efforts across CMS programs to achieve health equity. The plan underlines the importance of health equity data collection and outlines the next steps for CMS to improve data collection efforts and, in turn, advance health equity.
HHS ASPE: Racial/Ethnic Differences in Children’s Mental Health Services Use Before and During COVID-19 (11/9) – The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report
on the racial and ethnic disparities in mental health service use among children during the COVID-19 pandemic. The size of the decline in mental health service use varied by race and ethnicity, and was larger for Black (-11 percent), Hispanic (-five percent), and Asian (-three percent) children than White children (-one percent).
CMS: The CMS Innovation Center’s Strategy to Support Person-centered, Value-based specialty Care (11/7) – The CMS Innovation Center published a blog outlining its strategy to support testing models and tools to improve access to high-quality, value-based specialty care, along with a one-year report on the implementation of its refreshed strategic vision and objectives, which were originally announced in fall 2021. The report outlines actions taken to work toward better care for beneficiaries, through greater accountability for high-quality, person-centered care, more coordinated care, advancing health equity, increased access, and promoting transparency.
White House: The Biden-Harris Administration Advances Equity and Opportunity for Black Americans (11/6) - The White House released a statement outlining how the Administration has advanced equity and opportunity for Black Americans and communities across the country. This includes policies and programs protecting Black maternal health, increasing cultural competence for Black Americans with disabilities, eliminating barriers to USDA programs, diversifying the health care workforce, and more.
Department of Veterans Affairs: New data shows decline in Veteran homelessness since 2020
(11/3) – The US Department of Veterans Affairs (VA), Department of Housing and Urban Development (HUD), and Interagency Council on Homelessness announced preliminary results of the 2022 Point-in-Time Count showing an 11 percent decline in Veteran homelessness since early 2020, the last time a full count was conducted. This is the biggest drop in Veteran homelessness in more than five years.
HHS: Biden Administration Announces $4.5B to Lower Heating Costs This Winter (11/2) - HHS announced $4.5 billion in assistance to help lower heating costs for American families this winter. The Low-Income Home Energy Assistance Program (LIHEAP) funds will go to states, territories, and tribes to subsidize home heating costs and help families make cost-effective home energy repairs. The White House also released a fact sheet on new steps the Administration is taking to lower energy costs for families.
CMS: HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care (11/1) - CMS issued the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (PFS) Final Rule which updates payment rates and finalizes policy changes for Medicare payments under the Physician Fee Schedule, and other Medicare Part B issues, effective January 1, 2023. Notably, CMS finalized its proposal to implement a health equity adjustment to the quality performance score of Accountable Care Organizations (ACOs) that achieve a specified level of quality performance and serves beneficiaries in areas with a high Area Deprivation Index or serves a large proportion of dually eligible beneficiaries. Fact Sheet
MSSP Fact Sheet
CMS: HHS Approves Arkansas’ Medicaid Waiver to Provide Medically Necessary Housing and Nutrition Support Services (11/1) - CMS approved an amendment to Arkansas’ Medicaid section 1115 demonstration that will test interventions to address housing, food insecurity, and other health-related social needs. The amendment to the Arkansas Health and Opportunity for Me (ARHOME) demonstration will drive better health and wellbeing outcomes for beneficiaries in crisis by providing medically necessary support services, particularly for young people, pregnant and postpartum women, and those dealing with mental illness and substance use diagnoses.
ONC: Moving Standards to Support SDOH Data Capture from the Sandbox to Production
(10/27) – The Office of the National Coordinator for Health IT (ONC) published a blog on the launch of the Gravity Project Pilots Affinity Group that will pilot the Social Determinants of Health (SDOH) Clinical Care FHIR Implementation Guide (SDOH CC IG) as a way to further the development and adoption of SDOH standards.
HHS OMH: Addressing Community Health Literacy to Improve COVID-19 Health Outcomes (10/27) - Rear Admiral Felicia Collins, M.D., M.P.H. Deputy Assistant Secretary for Minority Health and Director, HHS Office of Minority Health published a blog on organizations and initiatives working to improve health outcomes by addressing personal and organizational health literacy.
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SDoH & Health Equity in the News
Health Affairs: Will the White House Pledge to End Hunger and Reduce Diet-Related Diseases Succeed (11/9) – On September 28, the White House held the Conference on Hunger, Nutrition, and Health and released a series of recommendations developed by an interagency workgroup tasked with ensuring a whole of government approach to address this issue. This article provides additional recommendations to build on this National Strategy, including having a systematic effort to prioritize, implement, and evaluate progress on recommendations within the Strategy.
Business Wire: Season Health Commits $5M in Partnership with Health Plans to Help 117 Million Americans Living with Nutrition Related Chronic Diseases and Food Insecurity (11/9) – Season Health, a food-as-medicine platform designed to address chronic condition management at scale, announced a commitment to further advance the company’s vision of a world well fed. In partnership with health plans, the company is committing $5 million to bring its food-as-medicine platform and healthy, affordable, culturally relevant meals to communities across the country.
Health Payer Intelligence: How AZ Medicaid Expanded its Role in SDOH Coverage (11/8) – The Arizona Health Care Cost Containment System (AHCCCS) received the Robert Wood Johnson Foundation’s 2022 Medicaid Innovation Award in “Initiatives to Address Social Determinants of Health” for its Whole Person Care Initiative. This initiative launched in 2019 to address SDOH needs among Arizona Medicaid beneficiaries, and provides transitional housing support, offers non-medical transportation support, reduces social isolation, and creates a statewide closed-loop referral system to enable connections to social services.
Health Affairs: Advancing Equity Through Value-Based Payment – Implementation and Evaluation to Support Design Goals (11/4) – The care delivery and payment flexibility possible under value-based payment (VBP) models, when paired with financial incentives to improve care quality and value, can make advancing equity a reality. This article identifies additional equity-focused VBP design components that other models may need to consider that were not employed in ACO REACH; highlights key implementation considerations for how CMS, states, and commercial payers can maximize equity in VBP model rollout by better engaging patients, providers, and other implementation partners; and provides a brief overview of where equity-focused evaluation is needed to assess the success of equity-focused design and implementation.
MedCity News: Food Insecurity is a Healthcare Issue. Here are 5 Ways Health Care Can Proactively Address It (10/31) – This article outlines five ways health care can address food insecurity to lead to better health outcomes. This includes creating nutrition education programs for clinical teams; implementing SDOH data in a standardized format; integrating foodRX as a core curriculum; going deep on mental health; and accelerating policy development for economic empowerment.
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Spotlight on Maternal Health
Kaiser Family Foundation: Racial Disparities in Maternal and Infant Health – Current Status and Efforts to Address Them (11/1) - Recently, there has been increased attention and focus on improving maternal and infant health and reducing disparities in these areas, including a range of efforts at the federal level. This brief provides an overview of racial disparities for selected measures of maternal and infant health, discusses the factors that drive these disparities, and provides an overview of recent efforts to address them.
Kaiser Health News: ‘Fourth Trimester’ Focus is Pushed to Prevent Maternal Deaths (10/31) – Maternal mortality review committees (MMRCs) look for clues about what contributed to maternal deaths to figure out how many of them could have been prevented. Recent data from the CDC revealed that 84 percent of pregnancy-related deaths were deemed preventable, and 53 percent of deaths occurred well after women left the hospital, between seven days and a year after delivery. This article explores this in more detail.
mHealth Intelligence: Mayo Clinic, Memora Health Launch Virtual Postpartum Care Research Program (10/28) – Mayo Clinic and Memora Health launched the first phase of a research program focused on virtual postpartum care. The program aims to improve communication between patients and providers through the addition of new technology to enhance postpartum care.
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Data & Innovation
American Public Human Services Association (APHSA): Launch of Digital Benefits Hub (11/9) – The Digital Benefits Network at the Beeck Center for Social Impact + Innovation at Georgetown University and APHSA introduced the Digital Benefits Hub in October. The platform is a first-of-its-kind, one-stop-shop for practitioners working to improve access to public benefits and services through data, design, and technology. The Hub provides access to toolkits, case studies, sample materials, and other resources related to benefits delivery.
AJMC: Improving Risk Stratification Using AI and SDOH (11/8) - Prediction models combining claims data with social determinants of health and additional, more-timely data sources using artificial intelligence (AI) can better identify individuals with the highest future medical spending. This study found that the AI model consistently identified a higher proportion of the highest-spending members. Members deemed highest risk by the AI model also had higher spending than members deemed highest risk by the Chronic Illness Disability Payment System model.
STAT: When it comes to caring for underserved patients, health tech is still figuring out what success looks like (11/3) - For startups and investors aiming to bring health technology to underserved populations, evidence of impact should be everything to show employers and payers a new offering is worth paying for, and to help convince patients to give it a try. However, there is still no industry-wide standard slate of metrics to fully evaluate products that meaningfully improve health for underserved groups. Measurement challenges also often extend beyond issues of access and equity.
Health Leaders Media: SDOH Measures, Baked into the EHR, Are Improving Patient Care (11/2) – Memorial Healthcare System is focusing on food, housing, and transportation to help reduce unnecessary emergency department visits and boost care quality. The health system is putting SDOH into its Epic electronic health record (EHR), which populates a problem list where doctors can see these factors with minimal extra work and act on them.
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New Research and Reports
Pediatrics: Understanding Racial, Ethnic and Socioeconomic Differences in the Ambulatory Care Experience (11/7) - Racial and ethnic and socioeconomic differences in patient experience are prevalent and can negatively impact health outcomes. The objective of this study was to examine differences in family experience of care in the pediatric ambulatory setting. As an overarching theme, discrimination and disrespect by staff undermined trust in care, affecting all aspects of experience.
Institute for Medicaid Innovation: Survey – Medicaid Health Plans Share Successes During COVID-19 Response, Identify Challenges in Data Collection and Sharing (11/4) – The Institute for Medicaid Innovation released its annual Medicaid Managed Care Organization (MCO) survey findings, which highlight the long-standing systemic issues with data collection and communication that affect enrollee care. The findings were broken into several fact sheets, including on social determinants of health. Among findings include that strengthened partnerships between Medicaid health plans and community-based organizations (CBOs) helped to address many front-line social drivers of health. Future investments in CBOs will support efforts to share data and support partnerships with managed care plans to identify and implement the most effective, evidence-based strategies.
AJMC: Social Determinants of Health Associated with Severe Visual Impairment (11/3) - A quality improvement study published in JAMA Ophthalmology found that severe visual impairment was affected by various social determinants of health, including low socioeconomic status, race, health care coverage and educational level. The researchers concluded that “ophthalmic health and vision were associated with SDOH and visual impairment was associated with various disparities in care and barriers to health care access.”
McKinsey & Company: Federal funding may boost SDOH infrastructure (11/1) - This analysis describes four federal financing mechanisms that are available to support SDOH data and analytics efforts and considerations for accessing them. While these insights primarily focus on possibilities for state Medicaid agencies, there are implications and potential opportunities for stakeholders across the ecosystem. The analysis provides a helpful starting point for planning and forming partnerships to support SDOH.
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Upcoming Events
November - December
2023
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SDoH Opportunities
November/December
Rolling Basis & 2023
- Deadline: January 6, 2023 – HRSA, Grant Opportunity: Rural Health Network Development Planning Program
- Deadline: January 17, 2023 – NIH, Funding Opportunity: John Lewis NIMHD Research Endowment Program
- Deadline: January 23, 2023 – National Institutes of Health, Research Opportunity Announcement: Community Partnerships to Advance Science for Society (ComPASS) Program: Community-Led, Health Equity Structural Intervention Initiative
- Deadline: February 6, 2023 – National Institutes of Health, Notice of Special Interest: Implementation Science to Advance Maternal Health and Maternal Health Equity for the IMPROVE Initiative
- Deadline: June 1, 2023 – HHS Administration for Community Living, Grants Notice: No Wrong Door Community Infrastructure Grants – Scaling Community Care Hubs through Lead Entities
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