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Social Determinants Updates

October 16 to October 30, 2020

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

In this newsletter, you will find updates on how the health care organizations are striving to meet health and social needs and invest in community health to improve health equity, 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

Unite Us: (10/29) – The Oregon Health Leadership Council and AFH member Unite Us have partnered to connect health and social care providers to create a collaborative network to address social needs throughout the state of Oregon.

STAT News: (10/28) – Marc Rothman, chief medical officer of AFH member Signify Health, co-wrote this article about how social needs could interfere with an equitable and universal distribution of a COVID-19 vaccine. As one solution, the article outlines the importance of home health providers in COVID-19 vaccine distribution, allowing seniors and other vulnerable populations to safely receive vaccinations, while also giving providers an opportunity to better understand patients’ chronic illnesses and intervene accordingly.

AJMC: (10/28) – At AFH member Alliance for Better Health’s CONVERGE Virtual Conference, experts discussed the role social determinants of health play in community-based health initiatives and how the COVID-19 pandemic has spurred partnerships across the continuum of care to optimize health outcomes.

Health Payer Intelligence: (10/23) – This article describes key social determinants of health domains payers can address, and highlights AFH members Blue Cross Blue Shield Association and UPMC for their research and work in addressing social needs, specifically BCBSA’s work to address lack of access to primary care providers and UPMC’s efforts to address housing and food insecurity.

Unite Us: (10/22) – AFH member Unite Us recently announced an expansion of its partnership with the Nebraska Health Information Initiative to bring coordinated care through an expanded behavioral health data platform to six additional states.

MobiHealthNews: (10/22) – AFH member Alliance for Better Health CEO Dr. Jacob Reider talks about the data and IT demands of coordinating social determinants of health efforts and the imperative need to serve underserved communities, where effects from COVID-19 will be felt for a long time.

Fierce Healthcare: (10/19) – AFH member Alliance for Better Health CEO Dr. Jacob Reider wrote this op-ed explaining the importance of language in health care, noting that there is a growing body of research that highlights a strong correlation between the social determinants of health and poor health. Changing the language used to speak about the intersection of health and social needs opens the door to important conversations that change the way health care is thought about.

AHA: (10/16) – In this week’s episode of the Advancing Health, AFH member American Hospital Association discusses using social determinants of health data to reduce breast cancer and one hospital’s efforts to reduce cancer disparities by addressing social needs, given that accessing mammograms is often more difficult for women who are low-income, lack transportation, or are unable to take time off.

Social Determinants Accelerator Act

GovExec: (10/28) – AFH Board Member Kathy Stack highlights that program implementation is as important as underlying policy, urging a new focus on intergovernmental collaboration and the relationship the federal government has with states and locations to foster innovation and improve outcomes. In the article, the Social Determinants Accelerator Act is highlighted as an example of a high-impact reform that would develop an interagency process to help states and localities address the complex needs of vulnerable populations by leveraging existing programs and waiver authorities.

SDoH in the News

Modern Healthcare: (10/28) – Blue Cross and Blue Shield of Illinois announced $100 million in new pilot programs to improve health outcomes for minorities and increase racial and ethnic diversity among medical professionals. The insurer will work closely with Illinois hospitals that serve large numbers of Blue Cross members in communities with people most at risk of contracting COVID-19 and aims to ultimately reduce racial and ethnic disparities in care.

PR Newswire: (10/27) – ConsejoSano, the patient engagement solution specializing in linguistically and culturally-aligned outreach, has partnered with RWJBarnabas Health and NowPow on Health Beyond the Hospital, the novel social determinants of health screening program.

Becker’s Hospital Review: (10/23) – Lyft partnered with Epic in early October on a new integration that allows healthcare workers to coordinate rides for patients directly from the EHR. In this interview, Megan Callahan, Vice President of Healthcare at Lyft, and Alan Hutchinson, Vice President of Population Health at Epic, discuss goals for the partnership in the year ahead as well as how the collaboration plans to continue building on initiatives to meet patients’ social needs.

Harvard Medical School: (10/23) – Harvard Medical School held a virtual forum entitled “Voting, Health Policy and Social Justice” to explore the political determinants of health. The keynote speaker indicated that although much has been learned about social determinants of health, current US economic and social policies still discriminate against people of color and have put them at greater risk for COVID.

Patient Engagement HIT: (10/22) – RWJBarnabas Health has unveiled Health Beyond the Hospital, a program codifying the healthcare organization’s commitment to addressing the social determinants of health.

AAMC: (10/15) – As an estimated 54 million people face food insecurity during the COVID-19 pandemic, there is a need to address this long-term problem and create solutions to barriers to access for millions of people who face additional food insecurity and health risks.

Modern Healthcare: (10/13) – In this op-ed, the CEOs of Feeding America and Anthem note that while food insecurity is not a new issue in America, the COVID-19 pandemic has made it far worse, necessitating more support to local food banks as one of the first and best ways to make an impact on food insecurity.

 Data Collection and Innovation

Health IT Analytics: (10/28) – Researchers at the Regenstrief Institute incorporated social determinants of health data into a machine-learning algorithm to improve its performance, finding that the model helps identify additional services patients may need during appointments, which led to an increase in referrals as well as patient attendance for appointments.

Healthify: (10/27) – Healthify, Algorex Health, and Excellus Blue Cross Blue Shield announced the results of a social determinants population analysis of Excellus’s members that identified high-risk members who had social needs and enabled Excellus to develop a targeted strategy focusing on addressing the social needs of members.

Medical Economics: (10/22) – There are several ICD-10 codes and code updates for 2021, including new guidelines for how physicians should report codes for social needs.

AJMC: (10/20) – Maryland’s COVID-19 task force on vulnerable populations leveraged data on social determinants of health to rapidly pinpoint populations most at risk of severe COVID-19 complications by partnering with social determinants data and analytics company Socially Determined.

CHCS: (10/19) – CHCS led the Data Across Sectors for Health initiative, which supports communities to strengthen and leverage existing relationships with state agencies in support of data-sharing efforts. Conducting interviews with thought leaders, CHCS extrapolated insights on the current priorities in the context of 1) COVID-19, an economic recession, and rising calls for racial justice, 2) new and emerging opportunities in support of data-sharing efforts, and 3) key ingredients for successful multi-sector data sharing efforts to improve health and advance equity.

NIMHD: (10/19) – The National Institute on Minority Health and Health Disparities (NIMHD) announced the availability of data harmonization tools for social determinants of health via the PhenX Toolkit, in an effort to encourage the minority health and health disparities research community to use new data collection tools emerging from this effort.

Manatt recently published an infographic, highlighting key findings from a national survey on how states leverage their Medicaid managed care contracts and 1115 waivers to address social needs and advance whole-person health.

Source: Manatt, How States Are Advancing Whole-Person Healthy for People with Medicaid

New Research and Reports

Patient Engagement HIT: (10/27) – A recent American Medical Association report found starker racial health disparities for Latinx communities, but contended that health disparities data may be underreported and therefore the analysis likely underestimates the extent to which the Latinx community is affected by COVID-19.

UnitedHealth Group: (10/26) – Researchers at UnitedHealth Group reviewed data from a number of sources, including CMS and the Robert Wood Johnson Foundation, and found that seniors living in counties with the highest health literacy saw better health outcomes. In the report, UnitedHealth Group estimated that if improving health literacy were a significant focus, Medicare could save $25.4 billion each year and avoid 993,000 hospital visits.

AJMC: (10/26) – A recent study presented during the American Society of Nephrology Kidney Week revealed certain social determinants of health can predict patient-reported outcomes (PROs) in potential kidney transplant patients. Understanding SDOH specific to a patient can inform transplant team knowledge of these issues and help improve PROs.

Manatt: (10/22) – In its latest report, Manatt provides a comprehensive review of states’ social determinants of health initiatives through Medicaid managed care contracts and 1115 waivers. The report outlines strategies states can employ to integrate SDOH into the Medicaid delivery system and leverage 1115 waivers to foster innovation. Manatt also published an infographic, which highlights findings from a national survey on how states are leveraging their Medicaid managed care contracts and 1115 waivers to address social determinants of health and advance whole-person health.

Altarum: (10/22) – A recent report examined the responses of several PACE organizations during the initial COVID-19 outbreak, highlighting how PACE providers have innovated and adapted to keep enrollees safe in their communities, including addressing both medical and biopsychosocial needs.

EHR Intelligence: (10/21) – A study published in JAMA Network Open revealed that integrating patient-reported social determinants of health data into an EHR can better identify individuals who are at a high-risk for hospitalization. SDOH data can be crucial to finding significant health issues and can create opportunities to offer social services and interventions for high-risk patients.

Patient Engagement HIT: (10/20) – According to a study published in JAMA Network Open, patients who hear about different options for social services referrals prior to a SDOH screening are more likely to accept assistance than those who don’t. This finding can influence how providers conduct screenings moving forward.

Milbank Memorial Fund: (10/20) – While value-based payment has the potential to spur innovation in upstream prevention, there is uncertainty about the conditions under which it would encourage health care providers to innovate to address upstream social risks. This study looked at the number of social risks systematically screened by practices, the extent of the practices’ participation in value-based payment models, and measures of capacity for innovation

AJMC: (10/19) – This study found that among patients receiving primary care within a large health system in South Florida, patient-reported social determinants of health variables were significantly associated with Framingham Risk Score-Cardiovascular Disease (FRS-CVD), and an increasing social risk score was significantly associated with a higher FRS-CVD, worsening of most modifiable CVDrisk factors, and higher odds of not achieving CVD benchmarks.

Big Cities Health Coalition: (10/19) – The Big Cities Health Coalition published a transition paper outlining critical public health recommendations for the next Administration and 117th Congress to implement to address COVID-19, substance use, systemic racism, and other health threats.

Center for Health Care Strategies, Inc.: (October 2020) – In partnership with the Association for Community Affiliated Plans (ACAP), CHCS developed a report to assess the ability of Dual Eligible Special Needs Plans (D-SNPs) to address their members’ social risk factors and explores policy options that would allow Medicare to provide D-SNPs the necessary tools to address social needs.

ASPE: (10/16) – ASPE released a report which provides projections of poverty rates and eligibility for Medicaid, TANF, and SNAP for the August to December 2020 period. Findings suggest that eligibility for all programs is projected to increase, and that annual poverty for 2020 is projected to rise above 13 percent by the year’s end.

Siren: (October 2020) – A recent study looked at whether randomization to permanent supportive housing (PSH) can reduce the use of acute health care services among chronically homeless high users of publicly funded services compared to usual care sources. The study found that PSH decreased psychiatric ED visits and shelter use, increased outpatient mental health care, but did not decrease medical ED visits or hospitalizations.

Science Direct: (10/7) – Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. This study looked at the needed capabilities and solutions for implementing AHCs to provide more integrated, high value care for children.

CDC: (October 2020) – The CDC released its Youth Risk Behavior Surveillance Data Summary & Trends Report: 2009-2019. The report highlighted trends in data on health behaviors and experiences among high school students related to sexual behavior, high-risk substance use, experiencing violence, and mental health and suicide.

ATI Advisory: (October 2020) – ATI analyzed CMS data on plan benefit packages finding that a growing number of plans are offering non-medical supplemental benefits under the expanded definition of primarily health-related benefits. In 2020, 499 plans offered non-medical supplemental benefits, while in 2021, 738 plans are offering these benefits.

Center for Health Care Strategies, Inc.: (October 2020) – The COVID-19 pandemic has revealed that individuals who are dually eligible for Medicare and Medicaid are among the most at-risk for contracting the virus but often receive care in fragmented systems. This report, developed in partnership with Speire Healthcare Strategies and Arnold Ventures, provides insight on response efforts from states and health plans that integrate programs and outlines recommendations to support integration.

Legislative Roundup

Health for MOM Act: (10/26) – Sens. Portman (R-OH) and Stabenow (D-MI) introduced the bipartisan HEALTH for MOM Act (S. 4863), which would provide states the option to provide coordinated care through a pregnancy medical home for high-risk pregnant women.

Connected MOM Act: (10/26) – Sens. Cassidy (R-LA), Hassan (D-NH), Young (R-IN), and Carper (D-DE) introduced the bipartisan Connected Maternal Online Monitoring Services (MOM) Act (S. 4859), which would require CMS to make recommendations for improving maternal and child health outcomes using remote physiologic monitoring devices and expanding coverage of such devices under Medicaid.

Mental Health Justice Act: (10/20) – Rep. Porter (D-CA) and 28 cosponsors introduced the Mental Health Justice Act (H.R. 8639), which would authorize the Secretary of HHS to award grants to states and political subdivisions of states to hire, employ, train, and dispatch mental health professionals to respond in lieu of law enforcement officers in emergencies involving one or more persons with a mental illness or an intellectual or developmental disability.

Health Equity Accountability Act: (10/20) – Sen. Hirono (D-HI) and eight cosponsors introduced the Health Equity Accountability Act (HEAA) (S.4819), which would improve the health of minority individuals. This legislation also includes the Social Determinants Accelerator Act, a bill that Aligning for Health has endorsed.

Family Support Services for Addiction Act of 2020: (10/19)– The House passed by voice vote the Family Support Services for Addiction Act of 2020 (H.R. 5572), which would direct SAMHSA to award grants to certain nonprofits to develop or expand services for individuals struggling with substance use disorders and their families. The bill now moves to the Senate for consideration.

Protecting the Health and Wellness of Babies and Pregnant Women in Custody Act: (10/19) – The House passed by voice vote the Protecting the Health and Wellness of Babies and Pregnant Women in Custody Act (H.R. 7718), which would address the health needs of incarcerated women related to pregnancy and childbirth. The bill now moves to the Senate for consideration.

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