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.
CareSource: (6/24) - Nationwide Children’s Hospital’s Healthy Neighborhoods Healthy Families initiative, in partnership with CareSource and several other partners, announced the creation of the Linden Healthy Homes Fund. This initiative will invest $4.2 million into building and rehabilitating affordable, high-quality rental housing for individuals living in South Linden, OH. As part of its initiative to invest in affordable housing, CareSource chose the Linden Healthy Homes Fund as the first beneficiary of this commitment.
Business Wire: (6/23) - Priority Health announced a first-of-its-kind “full lifecycle” social determinants of health (SDOH) initiative, partnering with groups including Socially Determined, ConsejoSano, and Aunt Bertha to create the data-driven, full lifecycle approach to addressing SDOH. Priority Health Connect, an online platform, will be powered by Aunt Bertha and designed to connect individuals with free and reduced cost programs and critical social services.
Kaiser Permanente: (6/22) - Kaiser Permanente, in partnership with Unite Us, launched the Mid-Atlantic Community Network (MACN) in Northern Virginia. This network will help address vital social needs that have been exacerbated by COVID-19 through a comprehensive community resource linking social service organizations, health care providers, and public agencies in the region.
American Hospital Association: (6/17) - This episode of the American Hospital AssociationAdvancing Health podcast features part two of a series of podcasts on rebuilding maternity services at a critical access hospital. Officials from the UNC School of Medicine at Chapel Hill and Chatham Hospital UNC Health Care at Siler City, N.C., discuss how a plan was fulfilled to reintroduce safe and sustainable maternity services. Listen here, and hear the first part here.
U.S. House Committee on Rules: (6/16) - Erine Gray, CEO and Founder of Aunt Bertha, spoke as part of a roundtable hosted by the U.S. House Committee on Rules entitled “Ending Hunger in America: Examining How Technology Can Help Combat the Hunger Crisis.” In his remarks, Gray said “we have the opportunity to envision a new safety net. It must be responsive - not just to trends, but to individual people - right in their moment of need.”
BlueCross BlueShield of Illinois: (6/16) - BlueCross and BlueShield of Illinois, a health plan of BlueCross Blue Shield Association, has joined forces with Feeding America to award over $150,000 in funding to four organizations committed to combating food insecurity across Illinois. This is just one effort of the health plan’s work to address food access and nutrition education in the state.
On Thursday, June 24, the House Energy & Commerce Committee, Subcommittee on Health held a legislative hearing entitled “Empowered by Data: Legislation to Advance Equity and Public Health.” Aligning for Health is thrilled that the Subcommittee convened this hearing to examine the importance of legislation to advance equity and public health.
The hearing featured 13 bills to advance equity and public health, including the Social Determinants Accelerator Act of 2021 (H.R. 2503). Several members specifically highlighted this legislation, emphasizing its importance in addressing SDOH for Medicaid beneficiaries and developing interagency councils to help communities use funds to better address the health and social needs of the population. Witness Dr. Kara Odom Walker of Nemours Children’s Health System also highlighted this legislation in her written testimony as a bill that would have a meaningful and lasting impact on addressing SDOH.
Aligning for Health submitted a statement for the record to Committee leaders and produced a summary of the hearing. We will also send a letter to the leaders of the House Energy & Commerce Committee and Health Subcommittee next week, thanking them and expressing support for the forward momentum towards passage of the Social Determinants Accelerator Act.
Rep. Underwood: (6/17) - Reps. Underwood (D-IL), Kelly (D-IL) and Adams (D-NC) and Sen. Booker (D-NJ) led 163 Members of Congress urging House and Senate leadership to prioritize policies to address the US maternal health crisis in the next COVID recovery package. The members are pushing for the inclusion of the Black Maternal Health Momnibus Act (H.R. 959) and a permanent expansion of yearlong postpartum Medicaid coverage. Members emphasized that these policies are necessary investments to save lives, advance health equity, and affirm the fundamental principle that every family has a right to thrive—a principle that begins with a safe and healthy pregnancy and birth. The full letter can be found here.
H.R. 3969: (6/17) - Reps. Curtis (R-UT) and Cardenas (D-CA) introduced legislation (H.R.3969) that would address social determinants of health in the calculation of medical loss ratios for group and individual market plans..
Reducing COVID-19 Disparities by Investing in Public Health Act: (6/15) - Reps. Hayes (D-CT) and Thompson (D-MS) introduced the Reducing COVID-19 Disparities by Investing in Public Health Act of 2021 (H.R.3904), which would increase the annual funding for the Chronic Disease Prevention and Health Promotion Fund, the National Institute on Minority Health and Health Disparities, and the Offices of Minority Health within the Office of the Secretary of Health and Human Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Food and Drug Administration, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration to enable the United States and State departments of public health to better combat disparities that have emerged during the COVID-19 crisis and beyond.
CARING for Social Determinants of Health Act: (6/15) - Reps. Blunt Rochester (D-DE) and Bilirakis (R-FL) introduced the Collecting and Analyzing Resources Integral and Necessary for Guidance (CARING) for Social Determinants of Health Act of 2021 (H.R.3894), which would issue and disseminate guidance to States to clarify strategies to address social determinants of health under the Medicaid program and the Children's Health Insurance Program.
BRIDGE Act: (6/15) - Sens. Bennet (D-CO), King (I-ME), and Portman (R-OH) introduced the Broadband Reform and Investment to Drive Growth in the Economy (BRIDGE) Act of 2021 (S. 2071), which would provide grants to states, territories, Puerto Rico, DC, and eligible Tribal entities to promote access to affordable, high-speed broadband and digital equity.
Trafficking Survivors Housing Act: (6/15) - Reps. Beatty (D-OH) and Wagner (R-MO) introduced the Trafficking Survivors Housing Act of 2021 (H.R. 3891), which would require a study and report on the housing and service needs of survivors of trafficking and individuals at risk for trafficking. The bill would focus on improving housing and homeless services for trafficking survivors to help them rebuild their lives. Sens. Brown (D-OH), Blunt (R-MO), and Durbin (D-IL) introduced companion legislation in the Senate (S. 2049).
Tribal Health Data Improvement Act: (6/11) - Reps. Mullin (R-OK) and O’Halleran (D-AZ) introduced the Tribal Health Data Improvement Act (H.R. 3841), which would amend the Public Health Service Act with respect to the collection and availability of health data with respect to Indian Tribes.The bill would expand tribal access to public health care data and surveillance and would require the CDC to address collection and availability of health data for American Indians and Alaska Natives. In addition, the bill provides grants to tribal epidemiology and public health centers to address under-sampling and misclassification of tribal populations and improve quality and accuracy of health data. The bill passed the House on June 23.
ASSET Act: (6/11) - Rep. Gomez (D-CA) and 10 cosponsors introduced the Allowing Steady Savings by Eliminating Tests (ASSET) Act (H.R. 3822), which would eliminate asset or resource limits employed by certain federally funded means-tested public assistance programs (TANF, SNAP, and LIHEAP). The bill would also raise the asset limitation for Supplemental Security Income (SSI) from $2,000 to $10,000 for an individual and from $3,000 to $20,000 for a couple, indexed to inflation.
Hunger-Free Summer for Kids Act: (6/10) - Sens. Boozman (R-AR) and 13 bipartisan cosponsors introduced the Hunger-Free Summer for Kids Act (S. 2005), which would amend the Richard B. Russell National School Lunch Act to require alternative options for summer food service program delivery. The bill would increase flexibility for the USDA’s Summer Food Service program and provide states additional options to reach hungry children in communities without a centralized feeding site during the summer.
To view a full list of the legislation we are tracking around social determinants of health, health equity/disparities, and maternal health, click here.
The NOFO provides an opportunity for state governments, Native American tribal governments, special district governments, county governments, Native American tribal organizations, and city or township governments to apply for up to $125,000 in grant funding. CDC will grant up to 20 awards.
Grant awards may be used to convene and coordinate a Leadership Team consisting of multisectoral partners to develop an implementation-ready Social Determinants of Health Accelerator Plan. Aligning for Health published a blog post this week outlining more details on who is eligible for the grant, what the grants can be used for, and highlighting examples from Live Well San Diego and the Cross-Sector Innovation Initiative to show what this could look like in practice.
ONC: (6/17) - ONC issued a blog on a health IT framework for advancing social determinants of health (SDOH) data use and interoperability. ONC focuses on four key areas with respect to how health IT can be used to help achieve this: standards and data; infrastructure; policy; and, implementation. In the infrastructure space, ONC is currently developing a toolkit to support states, payers, community-based services entities, and other stakeholders with their implementation of SDOH-based data exchange within their communities.
ONC: (6/17) - ONC issued a Notice of Funding Opportunity for the Public Health Informatics & Technology Workforce Development Program (PHIT Workforce Program), an $80 million program to strengthen U.S. public health informatics and data science. As part of this launch, ONC is inviting college and universities representing underrepresented communities to apply for funding through a consortium that will develop the curriculum, recruit and train participants, secure paid internship opportunities, and assist in career placement at public health agencies, public health-focused non-profits or public health-focused private sector or clinical settings. Applications are due August 11.
AHRQ: (6/15) - AHRQ announced a new tool that helps primary care practices assess patient’s social needs. The tool helps practices screen and refer patients to address their unmet social needs such as access to adequate food and housing.
HHS: (6/14) - HHS awarded $125 million to support 14 nonprofit private or public organizations to reach underserved communities and support a community-based workforce that will engage in locally tailored efforts to build vaccine confidence and bolster COVID-19 vaccinations in underserved communities.
Department of Veterans Affairs: (6/9) - The Department of Veterans Affairs (VA) hosted the 2021 Minority Summit, which centered around strengthening and expanding its relationships with minority-serving colleges, universities and medical schools, and professional organizations.
AHRQ: (6/8) - HHS Agency for Healthcare Research and Quality (AHRQ) released a new online data visualization tool that gives analysts access to social determinants of health (SDOH) data related to people’s access to the internet. The resource features a map of the United States showing county-level percentages of households with computers and smartphones and percentages of households with any type of high-speed internet access. The map also shows county-level percentages of individuals in poverty.
SDoH in the News
RAC Monitor: (6/23) - The RISE Association recently held its Annual Social Determinants of Health Summit, where topics such as legislation to support programs addressing SDOH and continuing mandates for funding and reimbursement of innovative programming were discussed. This article provides a roundup of the important legislation and federal funding related to SDOH and health equity that are currently being considered in D.C.
Health Affairs: (6/23) - The number of Americans facing food insecurity has increased significantly as a result of the pandemic, rising from 35 million to over 50 million who are currently food insecure. Health care organizations can play a pivotal role in addressing the unmet social needs of patients, and have been partnering with community-based organizations to develop innovative approaches to addressing food insecurity. This blog identifies four strategies that have been central to the success in programs aimed at increasing food access and reducing food insecurity in disadvantaged populations. The blog also describes each approach and provides examples of effective implementation at the community level to meet the specific needs of the population.
PR Newswire: (6/23) - Feeding America received a $1 million grant from the Anthem Foundation to expand its Food is Medicine program, where health care staff conduct universal food insecurity screenings and partner with local food banks to implement interventions. This funding will help support 14 Feeding America member food banks as they collaborate with health care partners to screen patients for food insecurity during outpatient visits and connect patients who screen positive to food assistance resources both on site and within the community.
Forbes: (6/23) - Lloyd Dean, CEO of CommonSpirit Health, has made it a core mission to improve access to care and promote health equity for all. To do so, he has prioritized collaboration, community outreach, and addressing social determinants, while also building on lessons learned from the pandemic. CommonSpirit is also focused on housing, with nearly 45 percent of the system’s community program investments going toward establishing affordable housing projects and improving low-income neighborhoods to prevent homelessness.
Modern Healthcare: (6/22) - Dozens of studies have been published over the past decade to look at whether addressing patients’ social needs improves their health and lowers medical costs. Results have not made clear which strategies to address SDOH are most effective or feasible, and interventions that are promising typically only serve a small number of patients. Public and private health plans across the country are launching initiatives to improve health by addressing unmet social needs - this article provides an overview of the various initiatives underway and the investments and impact involved.
Fierce Healthcare: (6/22) - Through the Moms’ Meals program, Humana members are beginning to see improvement in their health and quality of life. This pilot food delivery program, which is part of Humana’s effort to address members’ health-related social needs, aims to boost the health of the communities it serves. At the end of the pilot, 86 percent of participants agreed the home delivery of diabetes-friendly meals was paramount to their overall well-being.
Health IT Analytics: (6/17) - Gateway Health Plan partnered with the 1889 Jefferson Center for Population Health to improve the outcomes of expecting mothers and babies through its Community Care HUB. This program focuses on care coordination with community partners - eligible mothers will be connected to a community health worker who works individually with the mother to identify her specific needs, and can be connected to the program that best addresses these needs.
UConn Today: (6/17) - UConn Health medical students have developed and trained over 100 volunteer students to conduct screenings of UConn Health patients for any health equity barriers. The volunteers then follow up on any of the social needs revealed by advocating on the patient’s behalf and connecting them with necessary services they need to address their needs.
Inside Health Policy: (6/16) - President Biden’s proposal to invest $400 billion in home- and community-based services (HCBS) would boost funding for social determinants of health within the HCBS program, and some health care stakeholders are optimistic the investment could be a step towards broader social determinants funding. HCBS has been one of CMS’ primary vehicles for tackling SDOH for decades. If enacted, the funding would lead to a big boost in money available for HCBS programs that get at social determinants, like home accessibility adaptations and non-emergency medical transportation.
American Public Human Services Association: (6/16) - One of the biggest impediments to improving the impact of government programs serving vulnerable and marginalized populations is a lack of insight into the complex factors that contribute to better outcomes. To understand the root causes of poor health and economic security and develop effective solutions, governments must be able to integrate and analyze data from siloed services that serve those populations. The lack of state and local resources has prevented many states and localities from prioritizing integrated data and analytics, however the American Rescue Plan provides an opportunity to change this through the State and Local Fiscal Recovery Fund. Guidance from the Treasury indicated that states and localities can use these funds to build and strengthen cross-program analytics capacity, which could help advance equity and improve outcomes.
Health Affairs: (6/14) - This blog post attempts to outline another approach to catalyze sustainable investment in SDOH. This approach, a concept referred to as aggregated precision investment (API), harnesses the use of individual-level SDOH data and technology to identify precision SDOH investment opportunities and mitigate the need to formally convene stakeholders in a market.
Center for Health Care Strategies: (6/14) - The Virginia Department of Medical Assistance Services (DMAS), the state’s Medicaid agency, has taken steps over the past several years to address equity both internally and externally. In this blog post, Rebecca Dooley and Mariam Siddiqui of DMAS discuss efforts, challenges, and successes in building a culture of equity, and share advice for other state Medicaid agencies that are considering similar equity work.
State of New Jersey: (6/11) - New Jersey Governor Phil Murphy signed legislation that would create the COVID-19 Pandemic Task Force on Racial and Health Disparities. The Task Force was strengthened with revisions by the Governor to add additional members. On the bill’s passage, Governor Murphy said “The COVID-19 pandemic has disproportionately impacted our minority communities and we must work together to eliminate the existing racial disparities in health care. The revisions sent back to the Legislature further strengthen this bill and will bring together the perspectives and expertise necessary to achieve equity and meaningful healthcare reform.”
NIH: (6/9) - In this episode of the National Institutes of Health Intramural Research Program podcast, Speaking of Science, Dr. Anna Napoles of the National Institute of Minority Health and Health Disparities (NIMHD) talks about what she calls a new dawn for minority health. She discusses her work in reducing the types of hurdles that once hindered her parents so that all populations can live long, healthy, and productive lives.
New Research and Reports
Weill Cornell Medicine:(6/21) - Researchers at New York Presbyterian and Weill Cornell Medicine looked at economic and social conditions impacting individual and group differences in health status in Brooklyn and top barriers to cancer care. The study found significant barriers to care that include economic stability, education, and community and social context. Economic instability was the greatest barrier to cancer screening and treatment, as it impacted access to patient access to transportation, food, and medicine.
Patient Engagement HIT:(6/18) - According to a recent study published in JAMA, social isolation can have a negative effect on mental and physical health outcomes. The study found that individuals in long-term care facilities had a 17 percent higher risk of 30-day mortality when the facility was in a socially isolated location.
JAMA Network Open: (6/17) - This study looked at whether Black patients hospitalized with COVID-19 had worse outcomes than White patients, and if so, what the association was between worse outcomes and comorbidities and the hospitals they attended. Researchers found that the odds of 30-day inpatient mortality or discharge to hospice were 11 percent higher for Black patients than for White patients after adjustment for patient sociodemographic and clinical characteristics. This suggests that the increased mortality among Black patients hospitalized with COVID is associated with the hospitals where Black patients disproportionately received care.
Population Health Management: (6/16) - Recognizing that social factors influence patient health outcomes and utilization, health systems have developed interventions to address patients' social needs. Care coordination across the health care and social service sectors is a distinct and important strategy to address social determinants of health, but limited information exists about how care coordination operates in this context. This study looked at the coordination of health care and social services in the US, with results indicating that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services.
Patient Engagement HIT: (6/14) - New data from the Kaiser Family Foundation found that racial health disparities in COVID vaccinations remain despite increases in access and uptake among historically marginalized populations. The share of vaccinations among Black people is notably smaller than their share of both COVID-19 deaths and the total US population. Thirty-one percent of Black people across the country have received at least one shot, which is lower than their share of the total population in some states. It also dwarfs their share of COVID-19 vaccinations and deaths.
Center for Health Care Strategies: (June 2021) - The Center for Health Care Strategies partnered with In-Sight Associates, Health Management Associates, and Schoen Consulting to develop a series of resource packages that share best practices for supporting the integration of community health workers and promotores (CHW/Ps) into Medicaid managed care programs serving California’s Medi-Cal members. This resource focuses on data and evaluation strategies that managed care plans designing CHW/P programs can use to support health and social care integration and assess CHW/P activities.
SDoH Data and Innovation
Data.org: (6/15) - Data.org recently launched the Rising Equitable Community Data Ecosystems (RECoDE) project, which is a collaboration with DASH, Health Leads, and the National Alliance Against Disparities in Patient Health. The purpose of this initiative is to support the development and evolution of community data ecosystems with an equity-first lens to understand how to enable effective and meaningful data sharing to strengthen public health systems, expand access to critical social benefits, and improve population health.
Healthcare IT News: (6/14) - RTI International is developing an artificially intelligent approach to risk adjustment for social risk factors using random forests to understand life expectancy variances at the census tract level. With a combination of statistical and data science methods, researchers can drill down into different domains of SDOH and start to understand what is driving local variation in population outcomes like life expectancy.