Welcome to Aligning for Health's bi-weekly Social Determinants Updates newsletter.
In this newsletter, you will find updates on how 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.
American Hospital Association: (9/27) - In this episode of the American Hospital Association (AHA) podcast, Atrium Health executive Carol Lovin speaks with Sue Ellen Wagner, AHA vice president, trustee engagement and strategy, about board strategies to advance equity and diversity throughout the Charlotte, N.C.-based health system, which received the 2021 AHA Carolyn Boone Lewis Equity of Care Award.
Health Payer Intelligence: (9/24) - UPMC Health Plan’s Medicaid program, UPMC for You, partnered with Mom’s Meals beginning in October 2019 to launch a pilot program that provided home-delivered meals to 100 Medicaid beneficiaries. Members, who were part of the UPMC Community Health Worker Impact Program or Community Team Program who had nutrition-sensitive chronic conditions, received three meals per day for 13 weeks. In the six months after the service concluded, members saw a 31 percent decrease in emergency department use and a 36 percent decrease in median total health care costs.
CareSource: (9/23) - CareSource announced a $250,000 grant to the Ohio Association of County Behavioral Health Authorities, which represents the interest of Ohio’s county Alcohol, Drug Addiction, and Mental Health Boards. The grant will support health equity education, training, and programming through 2024 for those needing mental health and/or substance abuse prevention, treatment and recovery support services.
BCBS Massachusetts: (9/23) – Blue Cross Blue Shield of Massachusetts, a health plan of Blue Cross Blue Shield Association, shared the results of an analysis of racial and ethnic inequities in health care, and became the first health plan in the state to announce it will incorporate equity measures into its contracts and payment programs with clinicians who care for Blue Cross members.
CareSource: (9/20) - CareSource, along with United Way of Greater Cleveland, The Rose Centers for Aging Well and ten additional hospital and health insurance providers, is funding an innovative new initiative designed to improve the lives of individuals in Cleveland. The Collaborative Investments + Health program will deliver medically tailored meals to the homes of 300 participants and provide volunteer outreach to reduce social isolation and improve health of older adults who have chronic health conditions or lack accessible healthy food options.
Affordable HOME Act: (9/24) - Rep. Omar (D-MN) introduced the Affordable Housing Opportunities Made Equitable (HOME) Act (H.R. 5385), which would make housing affordable.
Medically Tailored Home-Delivered Meals Demonstration Pilot Act: (9/24) - Reps. McGovern (D-MA), Walorski (R-IN), Pingree (D-ME), and Evans (D-PA) introduced the Medically Tailored Home-Delivered Meals Demonstration Pilot Act of 2021 (H.R. 5370), which would require the Secretary of Health and Human Services to conduct a demonstration program to assess the effects of a hospital providing to qualified individuals medically tailored home-delivered meals. The bill would establish a Medicare pilot program to keep seniors healthy and address the critical link between diet and chronic illness.
House Select Subcommittee on the Coronavirus Crisis: (9/22) - The House Select Subcommittee on the Coronavirus Crisis released a staff analysis outlining evidence that the American Rescue Plan’s (ARP) relief provisions have alleviated economic hardship, reduced poverty, and supported economic recovery in the wake of the pandemic. Specifically, the report finds that following the ARP’s passage, as relief payments were disbursed, the number of Americans reporting that their households lacked enough food to eat dropped by 4.2 million.
TRIUMPH for New Moms Act: (9/21) - Sens. Hassan (D-NH) and Tillis (R-NC) introduced the Taskforce Recommending Improvements for Unaddressed Mental Perinatal & Postpartum Health (TRIUMPH) for New Moms Act of 2021 (S. 2779), which would provide for the establishment of a Task Force on Maternal Mental Health.
To view a full list of the legislation we are tracking around social determinants of health, health equity/disparities, and maternal health, click here.
Aligning for Health Submits Comments to Congressional SDOH Caucus RFI
Aligning for Health commented on specific SDOH challenges that most impact health, and how these areas have changed or been exacerbated by COVID-19; prominent barriers to addressing SDOH and innovative examples of programs that can offer solutions; and the role that coordinated networks can play in cross-sector coordination and data sharing. We also provided recommendations on how Congress can leverage existing opportunities to improve coordination and alignment between health and social services organizations; existing legislative approaches that seek to improve coordination, capacity and evaluation of SDOH initiatives; and policies and strategies to better coordinate eligibility and enrollment processes for cross-sector programs.
JAMA Network: (9/23) - This article examines how the US is doing in taking the steps necessary to address SDOH, and looks at the major obstacles in the way of implementing strategies to do so. Challenges highlighted include the need for better data sharing and to encourage cross-sector collaboration. The article also notes important developments that suggest there could be significant progress in the future, including references to the LINC to Address Social Needs Act, the Social Determinants Accelerator Act, and the Congressional SDOH Caucus.
AAMC: (September 2021) - AAMC published a report outlining three key themes that must be at the center of improving the nation’s pandemic preparedness: coordinated leadership, supply chain redundancy, and sustained investments and partnerships in public health and human resources in health care. The report put forward several recommendations, including that the government and private sector must invest in data infrastructure to promote health equity. One such solution mentioned was passing the Social Determinants Accelerator Act as a way Congress can support partnerships between stakeholders to address nonmedical factors of health.
CMS: (9/28) - The CMS Office of Minority Health released a report detailing the quality of care received by people enrolled in Medicare Advantage. The report builds on the racial, ethnic, and gender stratified reports released by CMS OMH since 2016 and the rural-urban stratified reports released since 2018. Findings demonstrate that overall, dual and Low-Income Subsidy beneficiaries often received worse clinical care than non-DE/LIS beneficiaries; the trends for worse clinical care persisted when results were stratified by race and ethnicity, though to a lesser degree for Hispanic beneficiaries. This analysis revealed more-pronounced disparities in clinical care for DE/LIS beneficiaries in urban areas than in rural areas.
HHS ASPE: (9/23) - HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) issued a report evaluating the current evidence from programs and policies targeting social determinants of health (SDOH). The report identifies the SDOH research questions, data sources, and data gaps that might be used to develop an SDOH research agenda and recommends building an HHS-driven SDOH research agenda, and research on how to integrate social services with health care.
GAO: (9/23) - GAO issued a brief on racial and ethnic health disparities. The two-page capsule draws from several GAO reports to provide examples of health disparities, and offers policy considerations to help the federal government better understand health disparities and promote health equity. GAO recommends reporting of race and ethnicity information by states, jurisdictions, and federal health systems and the routine analysis of health outcomes using these data. GAO notes that there are gaps in race and ethnicity data that must be addressed to better ensure agencies are meeting their health equity goals. This brief was published alongside a GAO blog that looks at GAO’s work on racial and ethnic health disparities.
NIH: (9/22) - The NIH recently announced a $50 million award to the University of North Texas Health Science Center to lead the coordinating center for the Artificial Intelligence/Machine Learning Consortium to Advance Health Equity and Research Diversity (AIM-AHEAD) program. The multi-institutional coordinating center brings together experts in community engagement, artificial intelligence/machine learning (AI/ML), health equity research, data science training, and data infrastructure. AIM-AHEAD was created to close the gaps in the AI/ML field, which currently lacks diversity in its researchers and in data, including electronic health records (EHRs).
HHS ASPE: (9/21) - ASPE released a brief on the impact of COVID-19 on children and youth. ASPE determined that COVID-19 has had significant impacts on the development, emotional and behavioral health, social, and economic well-being of children and youth, further exacerbating existing inequities. Furthermore, ASPE found that children and families involved with the child welfare system experienced increased stress and fewer services.
HHS ASPE: (9/20) - ASPE released a brief on the impacts of the COVID-19 pandemic on low-income families’ employment and income, economic well-being and physical and mental health. In terms of health, ASPE determined that the pandemic has exacerbated long-standing disparities in access to health care and healthy food for many families, especially low-income families of color.
HHS: (9/17) - HHS announced nearly $350 million in awards to every state across the nation to support safe pregnancies and healthy babies. Funding will expand home visiting services to families most in need, increase access to doulas, address health disparities in infant deaths, and improve data reporting on maternal mortality.
Hawaii.gov: (9/16) - A new CDC report, which contained data collected by the Hawaii Department of Health, revealed racial disparities in COVID-19 infections and death. Rates of infection and death were highest among Pacific Islander populations. Additionally, among Asian populations, infection rates were highest among the Filipino and Vietnamese populations. The data informed the Department’s COVID-19 response and emphasized the need to prevent and reduce inequities in social determinants of health, access to health care, and health conditions.
CDC: (9/15) - The CDC announced that 20 recipients across the country have been awarded funding through the Closing the Gap with Social Determinants of Health Accelerator Plans. This funding was provided to help accelerate actions in state, local, tribal, and territorial jurisdictions that lead to improved chronic disease outcomes among persons experiencing health disparities and inequities.
SDoH & Health Equity in the News
Health Leaders: (9/29) - Nashville General Hospital runs several programs to address social determinants of health and health equity for patients, including screening all patients for food insecurity and a “food pharmacy” where patients who qualify are referred for free food. The hospital also established a nonprofit called the Congregational Health and Education Network (CHEN), which has over 100 participating faith-based organizations and focuses on education attainment, health literacy, and health care access.
News 15: (9/29) - CVS Health announced it will invest $25 million to build 224 affordable housing units for families and seniors in Louisiana to address SDOH in underserved communities. CVS also plans to offer its Project Health no-cost biometric screening program to Louisiana communities next year.
Fierce Healthcare: (9/28) - Health plan AmeriHealth Caritas launched the Social Determinants of Life Inc. subsidiary, which aims to invest in, deploy, and support solutions to help people build resilience and improve their life outcomes. The company also invested $29 million in Wider Circle, a California-based startup that designs tech-enabled health programs and peer-to-peer social networks, to harness social networks and address social needs.
Healthcare IT News: (9/28) - Amazon Web Services (AWS) announced the launch of a new initiative to help organizations around the world build IT-powered social and health care programs to help patients in underserved communities. AWS pledged $40 million to help companies build and maintain programs that increase access to health care providers, tackle SDOH, and leverage data for more equitable and inclusive care delivery.
PR Newswire: (9/28) - March of Dimes announced a $300,000 grant from Blue Cross and Blue Shield of Louisiana Foundation to further support its work with the Humana Foundation to improve health outcomes for moms and babies. The funding will be used in Shreveport and New Orleans to mobilize cross-sector partners to address health inequities fueled by racial disparities and limited access to quality health care.
Johnson & Johnson: (9/28) - Johnson & Johnson announced the launch of its Health Equity Innovation Challenge to find and fast-track innovations that have the potential to diminish historical inequities among people of color. The challenge launched in six cities and invites innovators, entrepreneurs, and organizations to submit ideas for preventing and treating illnesses that disproportionately impact Black and Hispanic communities, enhance access to health care, advocate for trusted community-based health care, and create more diversity in science.
Harvard Health Publishing: (9/28) - This blog outlines the impact SDOH have on individuals struggling with addiction, pointing to existing evidence such as poverty and homelessness being risk factors for opioid overdoses. SDOH plays a significant role in framing the odds of whether people are able to treat and overcome their addiction, and factors like abruptly losing housing or other life events can trigger relapses or other poor outcomes.
Health Affairs: (9/27) - This article examines how the push to prescribe food as medicine may be inadvertently harming those who work in the food system who need that “medicine” the most. A systemic analysis of both food and health can align incentives to achieve the best outcomes for all involved. Identifying the right measures of success for health programs that include food and extending those measures to those who produced the food for the interventions can aid the food and health systems in this push to prescribe food as medicine.
HIT Consultant: (9/27) - Socially Determined has partnered with DataGen to bring SDOH insights to hospitals and health systems. Socially Determined will enrich the insights and analytics DataGen delivers to clients by providing access to social risk data and analytics through the SocialScape platform, while DataGen will enable Socially Determined to expand its footprint with providers across the country.
AJMC: (9/24) - Speakers during the Patient-Centered Oncology Care conference emphasized how important community engagement is in addressing disparities in cancer care. Speakers also discussed the impact of social determinants on health outcomes, stressing the need for more research and advocacy, as well as getting more clinical trials into the community to have more diversity in trials.
Patient Engagement HIT: (9/23) - AAMC established a Center for Health Justice to acknowledge the role medical education plays in establishing a future of health equity and to close health disparities in communities across the country. The Center for Health Justice will work to address how medical schools, teaching colleges, and research institutions can improve health equity through community health partnerships.
Center for American Progress: (9/23) - In light of COVID-19, rebuilding a stronger and more equitable future requires investing in social determinants. This article details five domains of SDOH - education, health care, economic stability, neighborhood and environment, and social and community context - and recommendations for budget reconciliation priorities to ensure the Biden Administration Build Back Better agenda prioritizes investments in programs that deliver health, economic, and environmental benefits to the communities that need them most.
Health Payer Intelligence: (9/22) - Health plans continue to face challenges in contracting with community-based organizations to address social determinants of health. Despite the rise in contracts between community-based organizations and payers or other health care entities, the efficacy of these contracts and contracting processes remains unclear.
Health Affairs: (9/16) - There has been continued interest in directing health care payment in ways that account for SDOH, avoid inappropriately penalizing providers who care for socially at-risk populations, and improve health outcomes. Some policy makers have turned to geographic measures largely due to the lack of robust individual-level SDOH data, with growing calls to use this type of approach more broadly in the US. This article explores this approach, and how several solutions can be used to implement it.
CVS: (9/15) - CVS Caremark announced an expansion of its efforts to decrease health disparities among patients with certain chronic conditions including sickle cell, HIV, and cardiovascular disease by collaborating with local partners and utilizing its unique enterprise assets. The company will invest in programs that address barriers to care, collaborate with community-based organizations to meet patients where they are, and develop other initiatives to address inequities.
New Research and Reports
NORC: (9/30) - According to new research from NORC at the University of Chicago, only 1.3 percent of Medicare beneficiaries had their social needs tracked in their 2018 health care claims. Researchers found that social needs were more frequently documented for beneficiaries who are racially and ethnically diverse, enrolled in Medicare Advantage, and dually eligible for Medicare and Medicaid coverage. Additionally, the use of Z codes, which document non-medical factors affecting patient health, was not distributed evenly across the US.
Health Affairs: (9/30) – Recent housing research has emphasized the effect of zoning and land use regulations on neighborhood characteristics and affordability. This brief summarizes the role that low-density residential zoning might play in health outcomes and health equity, given the plausible effects that local land use decisions have on housing affordability, segregation and disparities in the neighborhood environment.
Fierce Healthcare:(9/29) - The National Association of ACOs (NAACOS) released a white paper outlining a series of recommendations for CMS to better position accountable care organizations (ACOs) to address health equity. Among the recommendations include the need for upfront funding to help form ACOs in rural areas and more financial support to address health equity, as such supports are needed to address broad change around SDOH. The paper also states that more funding is needed to support an expansion of ACO social services that can address SDOH.
AcademyHealth: (9/23) - A recent study published in Health Services Research examined the degree to which the relationship between food insecurity and health is bi-directional, with an eye toward breaking the cycle and improving health. Researchers found that the relationship is bi-directional, but also unequal - while food insecurity is a predictor of health expenditures and vice versa, food insecurity had a greater impact on health care expenses than expenditures had on food insecurity.
Institute for Healthcare Improvement: (9/23) - The Institute for Healthcare Improvement (IHI) recently published a survey finding that the percentage of health care leaders naming health equity as a top three organizational priority more than doubled to 58 percent since 2019. Respondents answered questions as to what the top barriers are to advancing health equity, which included inconsistent collection of equity-related patient data, lack of resources other than funding, lack of funding, inability to demonstrate impact of health equity efforts, and lack of guidance or know-how on what to do next, among others.
Kaiser Family Foundation: (9/22) - This brief examines housing adequacy, affordability and internet access within the homes of Medicaid enrollees using data obtained prior to the pandemic and assesses the limited role Medicaid can play in helping to address these challenges. While housing insecurity and other social determinants can impact health, policies and programs outside of Medicaid were found to have the greatest impact on housing issues among the broader Medicaid population.
Patient Engagement HIT: (9/21) - In a recent brief in the Perspectives in Adult Education journal, the author writes how experts must address the link between health literacy and education to improve health outcomes for underserved populations, as low health literacy can pose threats to health and safety. Adults reading at elementary levels are also likely to have low health literacy, which can pose challenges in understanding information about COVID and public health guidance, as well as basic medication adherence.
Patient Engagement HIT: (9/21) - Data from the Lown Institute found that few top health care organizations rank high for health equity and social responsibility, despite statements by several organizations committing to health equity over the past year. The Lown Institute found that only 75 out of 3,000 assessed hospitals got an A ranking for health equity, and many of the biggest names in health care were not included on the list.
BMJ Health & Care Informatics: (September 2021) - COVID has exacerbated health disparities in the US, particularly among racial and ethnic minorities, which has shown a need for data-driven approaches to identify the clinical and social determinants that lead to poor patient outcomes. This study looked at county-level COVID data and SDOH data in Tennessee, and concluded that incorporating a data framework to track the evolving patterns of community-level SDOH risk factors could provide policymakers with additional data resources to improve health equity and resilience in future public health emergencies.
Data and Innovation
Health Leaders Media: (9/28) - In a recent white paper, the American Health Information Management Association (AHIMA) asserted that applying data governance strategies can help health care facilities capture and use SDOH data. The white paper identifies opportunities and challenges for organizations that want to use SDOH data to affect change.
Health Leaders Media: (9/28) - According to Institute for Healthcare Improvement President and CEO Kedar Mate, MD, health systems need to improve the collection, storage, and processing of patient data in order to address health equity. In this interview, Mate discussed the importance of data in the effort to ameliorate health inequities.
mHealth Intelligence: (9/24) - Several large corporations that are members of the Black Community Innovation Coalition announced they will create a health care platform featuring telehealth and mHealth services in early 2022, dedicated to reducing barriers to care access and improving health equity among Black Americans. This project will lead focus groups and other efforts that target asynchronous and synchronous data collection around top health issues faced by Black Americans, including maternal fetal health, cardiometabolic disease and access to primary care and behavioral health services.
Health IT Analytics: (9/20) - Health Center Partners (HCP) explored different data management tools to improve care quality and eliminate health disparities, and therefore better meet the needs of their patient population. As a major issue with data management is that data is often scattered across different systems but needs a mechanism to bring it together, HCP chose Arcadia as the tool aggregates the data leading to one record per patient in a master patient index which helps identify quality gaps.