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.
Health Evolution: (1/19) - In her first year as the President & CEO of the Blue Cross Blue Shield Association, Kim Keck has championed maternal health, health equity, community health, and coordinating on a national level to advance affordability and overall wellness. Health Evolution interviewed Keck about leveraging data to lay the foundation for a more equitable and affordable health care system, becoming part of the Health Evolution Equity Pledge, and her top priorities for the future.
American Hospital Association: (1/19) - The American Hospital Association released a 20-minute video to help hospital and health system boards advance health equity in their communities. Maria Hernandez, president and chief operating officer of Impact4Health, and Karma Bass, senior principal at Via Healthcare Consulting, discuss how boards can use a survey tool to better prepare for and focus health equity discussions.
UPMC Health Plan: (1/19) - The National Committee for Quality Assurance (NCQA) launched a pilot program to develop its Health Equity Accreditation Plus evaluation program in partnership with UPMC Health Plan and several other leading health organizations. This program helps health care organizations establish processes and cross-sector partnerships that identify and address social risk factors in their communities and the social needs of the people they serve.
Signify Health: (1/18) - CMS has acknowledged the need to gather data and improve data standardization to understand and address social determinants of health. In this article, Signify Health outlines how the home is an ideal place to collect this information and that in-home health evaluations help to identify and track the risk factors and collect comprehensive data to facilitate patient-centered, holistic coverage and care.
MedCity News: (1/18) - A growing number of transition programs are focused on health care planning - helping formerly incarcerated individuals with enrollment in Medicaid, and supporting them to access covered programs to treat medical and physical health conditions. In this article, Eric Beane, VP of Regulatory and Government Affairs at Unite Us, outlines the need for a system that increases access to community-based health and social services for justice-involved individuals to local resources to support them as they navigate reentry and reintegration into communities.
Fierce Healthcare: (1/12) - Signify Health recently presented at the JP Morgan Healthcare Conference and discussed its new partnership program to connect value-based solutions focused on improving care in and around the home with hospitals, health systems, payers and patients. The focus of the Signify Health Partner Program is on partner technologies and services that support behavioral health, remote patient monitoring, social determinants of health to close care gaps, member engagement, and care optimization.
ICD10monitor: (1/11) - This article reflects on the work of the Blue Cross Blue Shield Association to confront the nation’s racial health disparities through its National Health Equity Strategy. The strategy is intended to change the trajectory of health disparities, address SDOH to ensure improvements in all communities, and reimagine a more equitable health care system.
Medical Economics: (1/7) - In 2020 Cync Health, the state health information exchanges (HIEs) of Nebraska and Iowa, partnered with Unite Us to provide behavioral and social health information on the two states’ HIEs. Medical Economics interviewed Jaime Bland, DNP, RN, president and CEO of Cync Health, to learn more about the program and how social determinants data is being exchanged electronically.
SNAP Second Chance Act: (1/19) - Reps. Trone (D-MD), Katko (R-NY), Correa (D-CA) and Meijer (R-MI) introduced the SNAP Second Chance Act (H.R. 6432), which would limit the use of business integrity and reputation factors in determining eligibility of a retail food store or wholesale food concern to be approved to accept and redeem supplemental nutrition assistance program benefits. Expanding SNAP authorization to justice-impacted small business owners will help make a dramatic difference in areas with limited food retailers. One-pager
Medical Student Education Authorization Act: (1/13) - Sens. Inhofe (R-OK) and Rosen (D-NV) introduced the Medical Student Education Authorization Act of 2022 (S. 3497), which would establish a grant program to award grants to public institutions of higher education located in a covered state to expand or support graduate education for physicians in states with the most severe primary care provider shortages. This could include the development and implementation of curricula that considers social determinants of health in care plan development, among other areas. Reps. Cole (R-OK), Titus (D-NV), and Mullin (R-OK) introduced companion legislation in the House (H.R. 6397).
Digital Literacy and Equity Commission Act: (1/12) - Rep. Lawrence (D-MI) introduced the Digital Literacy and Equity Commission Act (H.R. 6373), which would establish the Digital Literacy and Equity Commission, which would bring together agency heads and experts to assess digital literacy in the US, recommend how to measure digital literacy, and promote interagency cooperation.
Innovations in Aging Act: (1/11) - Sens. King (I-ME) and Casey (D-PA) introduced the Innovations in Aging Act (S.3473), which would authorize funding for the Research, Demonstration, and Evaluation Center for the Aging Network in order to demonstrate the impact of the aging network on the health and independence of older individuals and to foster innovation in such network.
Building a Sustainable Workforce for Healthy Communities Act: (1/11) - Sens. Casey (D-PA), Tillis (R-NC), Smith (D-MN), and Murkowski (R-AK) introduced the Building a Sustainable Workforce for Healthy Communities Act (S.3479), which would provide awards to support community health workers (CHWs) and community health. Specifically, the bill would reauthorize a competitive grant program for eligible entities to develop or expand CHW programs, which could include recruiting and training CHWs who reflect the needs of the community and support outreach to underserved communities and those requiring additional assistance during a public health emergency.
Afterschool Meals Act: (1/6) - Reps. Brown (D-OH) and Hayes (D-CT) introduced the Afterschool Meals Act of 2022 (H.R. 6357), which would amend the Richard B. Russell National School Lunch Act to provide meals and meal supplements for children in afterschool care.
To view a full list of the legislation we are tracking around social determinants of health, health equity/disparities, and maternal health, click here.
United States Interagency Council on Homelessness: (1/19) - The U.S. Interagency Council on Homelessness released new federal guidance to help communities minimize the spread and impact of the Omicron variant of COVID-19 among people experiencing homelessness. The guidance continues to recommend a 10-day isolation and quarantine for people experiencing homelessness, regardless of vaccination status. The guidance also offers five strategies in cases where rehousing or non-congregate shelter are not an immediate option for quarantine or isolation.
CDC: (1/18) - The CDC posted the Year 1 Evaluation of the Social Determinants of Health - Getting Further Faster (GFF) pilot project, a collaboration by ASTHO and NACCHO that assessed the work of multi-sector coalitions to advance health equity by addressing social determinants of health. All 42 GFF partnerships built community capacity for addressing SDOH through new or strengthened partnerships, data, and data systems, or strategic plans; leveraged resources; or engaged residents, among other findings.
NIH: (1/14) - This blog by the NIH National Institute on Minority Health and Health Disparities details the relationship between age and social determinants of health with COVID-19 vaccine hesitancy in the Southern United States. The blog outlines a study that surveyed individuals on vaccine resistance, finding that the odds of vaccine resistance were seven times more likely in participants experiencing housing insecurity due to COVID-19, among other findings.
Fiddlehead Focus: (1/14) - The CDC recently provided the Aroostook County Action Program with a $125,000 grant to, in partnership with the Maine Resilience Building Network, develop a Social Determinants Accelerator Plan. The grant will support efforts to increase social connectedness and decrease food insecurity along with nutrition and education in Aroostook County.
Administration for Community Living: (1/13) - The HHS Administration for Community Living began distributing the $150 million in funding it had received from the Biden Administration to expand the public health workforce within the aging and disability networks. Half of the total funding will be awarded over the next two weeks; the remainder of the funding will be awarded on a rolling basis over the coming months.
CDC: (1/11) - The CDC launched the Operation Expanded Testing (OpET) program to increase access to testing nationwide. OpET provides no-cost testing to child care centers, K-12 schools, historically black colleges and universities (HBCUs), under-resourced communities, and congregate settings, such as homeless shelters, domestic violence and abuse shelters, non-federal correctional facilities, and other qualified sites.
Health Affairs: (1/11) - Center for Medicare Director Seshamani, Center for Medicare and Medicaid Innovation Director Fowler and CMS Administrator Brooks-LaSure issued a blog post outlining their vision and goals for the Medicare program: advance health equity; expand access to affordable coverage and care; drive high quality, person-centered care; and promote affordability and the sustainability of the Medicare trust fund.
CMS: (1/11) - CMS issued a request for comment on a proposal to pilot the collection of race and ethnicity data on Medicare Part C and D enrollment forms. Comments are due by March 14, 2022.
CMS Office of Minority Health: (1/11) - CMS Office of Minority Health has published a new report, “Trends in Racial, Ethnic, Sex, and Rural-Urban Inequities in Health Care in Medicare Advantage: 2009-2018”, which presents an analysis of historical trends in inequities by race, ethnicity, sex, and geography among Medicare beneficiaries enrolled in Medicare Advantage (MA) plans nationwide.
Department of Veterans Affairs: (1/11) - The Department of Veterans Affairs (VA) announced their cultural transformation action plan to become a federal model for inclusion, diversity, equity, and access for Veterans and employees. An 18-member I-DEA task force, created April 1, 2021, developed 20 recommendations and 68 sub-recommendations for the department to consider during the next four years to ensure all VA employees, Veterans, their families, caregivers and survivors have equitable treatment and experiences when interacting with VA.
Modern Healthcare: (1/11) - At the recent J.P Morgan Healthcare Conference, CMS Administrator Chiquita Brooks-LaSure said that the federal government will increase its partnerships with private companies and community groups in 2022 to bridge health disparities and reduce costs for public-covered patients. She also noted the role that large organizations can play in leveraging their purchasing power to align multiple payers toward addressing social determinants of health, and that CMS will be mindful of rewarding those organizations to take on risk for patients with multiple acuity levels.
SDoH & Health Equity in the News
Managed Healthcare Executive: (1/20) - CMS and states across the country are leading on tackling health equity and social determinants of health, especially in light of the inequities that have been exacerbated by COVID-19. This blog provides an overview of federal and state actions to address SDOH, and recommendations on how to sustain the work of established coordinating organizations beyond the pandemic and on addressing the lack of integration between health data, social care data, and consistent standards for SDOH data collection.
The Commonwealth Fund: (1/19) - The CMS Innovation Center has pledged to promote health equity by making it easier for providers serving racial and ethnic minorities to participate in alternative payment models (APMs), however community health centers that serve such populations are often not considered in the design of APMs. As health centers are well-positioned to address SDOH and take a population-based approach to care, this article profiles the health centers participating in a range of APMs to manage population health.
PR Newswire: (1/19) - CVS Health and Uber Health have partnered to provide critical transportation support at no cost to people in need of medical care, work or educational programs. The partnership is part of Health Zones, CVS Health’s new initiative that provides concentrated local investments designed to reduce health disparities and advance health equity in high-risk communities. Rides through Uber Health will be available to a target population living in three of the five Health Zones, and will enter additional cities later this year.
Health Leaders: (1/19) - The Physicians Foundation recently adopted the term “social drivers of health” rather than social determinants of health, and is pressing CMS to adopt new measures for social drivers of health to be included in payment models for health care services. One key principle is the imperative to create new standards for social drivers of health quality, utilization, and outcome measurement.
Patient Engagement HIT: (1/18) - A researcher at Wayne State University School of Medicine received a $2.5 million National Institutes of Health grant to improve health disparities by developing an effective mobile health intervention for young Black adults with asthma. The grant will help create the ATHENA Project, creating a system that will provide users with supportive accountability administered by nurses utilizing targeted mobile support to deliver educational material and help individuals overcome barriers through patient motivation techniques.
Health Affairs: (1/18) - One of the goals of the California Advancing and Innovating Medi-Cal (CalAIM) program is to “improve quality outcomes, reduce health disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform” for the Medicaid program. To deliver on its promise to address SDOH, improve prevention, offer social services, and more, the Medi-Cal program will need a new investment in health data. This piece explores how accurate, timely data are crucial to both the implementation of CalAIM and for tracking whether CalAIM is successful in improving health, addressing disparities, and reducing unneeded spending.
Truveta: (1/18) - Truveta has partnered with the health care business of LexisNexis Risk Solutions to improve the quality of all health research and enable new insights on health equity. According to the company, the partnership will facilitate the linkage of daily clinical data from over 16 percent of all clinical care in the US to health providers, and integrate the data with 40 percent of all Medicare and Medicaid insurance claims, 70 percent of all commercial medical claims, social determinant of health data, and comprehensive mortality data in one data platform for medical research.
National Academies of Sciences, Engineering and Medicine: (1/18) - At a recent National Academies workshop promoting health equity in cancer care, panelists remarked on how, if we’re not careful, disparities in who gets access to high-quality cancer care and treatments could persist and be exacerbated. Equitable cancer care starts with prevention and reaching people before they become patients, and patients should be asked if they are getting the care they need and if the things they need exist in their community.
Patient Engagement HIT: (1/14) - University Hospitals Cleveland Medical Center has awarded $1.2 million through its Community Health Investment Strategy to Lead Safe Cleveland Coalition, which works to address lead poisoning issues in the city. This public-private partnership will help address and prevent the issue of lead poisoning and help families and property owners make their homes lead safe.
Fierce Healthcare: (1/12) - Kaiser Permanente has partnered with Morgan Health to jointly collect and report health equity metrics for JPMorgan Chase employees based in California, and will roll out performance guarantees tied to health equity on certain quality measures for employees beginning in 2023.
NCDHHS: (1/12) - The North Carolina Department of Health and Human Services (NCDHHS) published its Olmstead Plan, which is designed to assist people with disabilities who receive or are eligible for publicly-funded services, and divert such individuals from entering institutions and support those wishing to leave. The plan outlines an approach to the many services and supports vital to community living, including access to housing, employment, home and community-based services, and other supports. The plan also expands the work to address SDOH as part of the Healthy Opportunities initiative.
Kaiser Health News: (1/12) - While states are required to set up transportation to medical appointments for individuals in the Medicaid program, many patients have experienced long wait times, no-shows, or even injuries from non-accessible transportation from these services, preventing them from accessing needed medical care. This op-ed outlines patient stories related to this issue.
HomeCare Magazine: (1/12) - Medicare Advantage plans are continuing to incorporate new services to address social determinants, including programs that address food insecurity. A recent comparison of 2022 plans found that meal and nutrition benefits are becoming an increasingly common offering, with 68 percent of plans including meal benefits and 30 percent of plans including nutrition benefits in 2022.
PR Newswire: (1/12) - The New York Healthy Homes Collaborative (NYHHC) announced the launch of an innovative $4.75 million home-based asthma reduction project to help children and adults across New York City. The project will focus on addressing the underlying causes of asthma, using private sector investments to establish sustainable Medicaid funding for preventive asthma services that address SDOH through a model that is scalable and replicable.
Health Affairs: (1/10) - While many health care associations and health systems have taken steps to better address social determinants of health in recent months, redressing the imbalance in spending in the US will require moving dollars out of health care spending and into social services. This article outlines how the Medicare Advantage (MA) program can play a role in this, and outlines a proposal that would allow MA plans to continue to offer their current supplemental benefits and premium levels and create a pay-for for Congress to address a range of improvements in social drivers of health.
Healio: (1/10) - A new American Health Association scientific statement outlined that clinicians must use multifaceted tools to reduce cardiovascular risk in type 2 diabetes and combine newer therapies with efforts to address social determinants of health. The statement included several key recommendations, including that clinicians must also address SDOH in the delivery of care or through referral-based pathway programs.
Spotlight on Maternal Health
Executives for Health Innovation: (1/20) - Executives for Health Innovation (EHI) and Philips Healthcare published a new report exploring the maternal health crisis. The report offers real-world examples and solutions designed to eliminate disparities in maternal health and reduce maternal mortality rates.
KATC News: (1/18) - Louisiana WIC partnered with Pacify Health to expand Louisiana’s ongoing work to improve breastfeeding duration rates for WIC participants by offering unlimited, 24/7 access to infant feeding support. This partnership supports Louisiana WIC’s mission to improve health equity by improving access to breastfeeding support services for people in rural areas and for non-English speaking participants.
AAMC: (1/18) - Black and American Indian/Alaska Native people are two to three times more likely to die from pregnancy-related causes than White people. But varied efforts - from culturally sensitive care to bias-targeting toolkits - are reducing gaps and saving lives. This article profiles several multifaceted efforts to address maternal health inequities across the country.
Health Day: (1/11) - A study in the Journal of the American Heart Association found that pregnant women in the US who face adverse social conditions where they live, work and play are at higher risk for poor heart health, which can lead to early cardiovascular disease and death. Cardiovascular disease is on the rise in the maternal death rate, and now accounts for one-third of all pregnancy related deaths.
Manatt: (1/10) - The CHIP coverage option for pregnant immigrants and their children that states may provide enables states to provide prenatal, labor and delivery, and postpartum services to pregnant individuals regardless of immigration status. This issue brief offers considerations for policymakers around the CHIP coverage option for pregnant immigrants and their children.
Fierce Pharma: (1/7) - Merck has invested $500 million to-date to address maternal mortality through its Merck for Mothers initiative, and recently announced it will invest an additional $150 million to the cause to support maternal health. The latest investment will aim to tackle worsening maternal health inequities amid the pandemic and improve reproductive and prenatal health services for 25 million women by 2025.
New Research and Reports
Health Payer Intelligence: (1/20) - A report from the Association for Community Affiliated Plans (ACAP) found that Medicaid plans have a key role to play in improving access to care and health equity for the LGBTQI+ community. The report noted several areas in which Medicaid programs can improve their care for LGBTQI+ individuals and offered four case studies to elucidate what community health plans are doing to address these areas.
Modern Healthcare: (1/19) - A new study by ATI Advisory found that a quarter of Medicare Advantage (MA) plans now offer chronically ill beneficiaries healthy food, transportation, and other special supplemental benefits in 2022, representing a nearly 40 percent year-over-year increase in uptake of these services. Adoption of such services in MA plans is being driven by the recognition of how social determinants impact an individual's conditions and overall health outcomes.
AJMC: (1/19) - Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structured data elements that could be used as components in future computable social risk factor phenotypes.
The Journal for Nurse Practitioners: (1/19) - The high correlation of poverty to social determinants of health suggests poverty screening could be a viable first step in SDOH screening. This study examined the relationship of SDOH to poverty and evaluated whether screening revealed needs previously unknown to providers, finding that nine of the 10 SDOH were correlated with positive poverty screening.
Health Affairs: (1/19) - This study used machine learning to analyze electronic health records from an urban academic medical center and to investigate whether providers’ use of negative patient descriptors varied by patient race or ethnicity. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes, which raises concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.
Journal of the American Pharmacists Association: (1/19) - To provide practical tools and resources for pharmacies to assess and mitigate social determinants of health with patients, the American Pharmacists Association published this article to highlight the numerous items available to provide culturally and linguistically tailored disease management, health communication, and to address food insecurity. The article uses tools and resources to address SDOH in the context of the Pharmacists’ Patient Care Process for a diabetes patient case.
American Heart Association: (1/18) - Disparities in cardiovascular disease outcomes is a stark reminder of health care inequities in the US. This review applies a comprehensive social determinants of health framework to better understand how structural racism increases individual and cumulative social determinants of health burden for historically underserved racial and ethnic groups, and increases their risk of cardiovascular disease.
Patient Engagement HIT: (1/18) - The Pharmacy Quality Alliance issued a new resource guide to help pharmacists navigate certain social determinants of health that might present when a patient visits a pharmacy. The guide features information about SDOH screenings, social services referrals, and other services pharmacists can employ to address SDOH, and details 20 real-world programs that help to address SDOH affecting a patient’s ability to access or manage medications.
PR Newswire: (1/13) - The National Alliance of Healthcare Purchaser Coalitions conducted a yearlong learning collaborative with the CDC Office of the Associate Director for Policy and Strategy and the National Network of Public Health Institutes to help employers address social factors that impact their employees’ health. Key findings included that employers used community data to identify potential issues and prevalence of social needs and risk by employee zip codes to better identify population health challenges and inequities, and several employers had long-term goals to integrate health equity into existing structures and objectives.
National Clinical Care Commission: (1/13) - The National Clinical Care Commission released its final report to Congress, outlining evidence-based, actionable recommendations to improve federal diabetes awareness, prevention, and treatment programs. The report calls for additional federal efforts to improve access to care, address the social determinants of health, and improve collaboration among different agencies.
Patient Engagement HIT: (1/12) - Recent data from the Boston University School of Public Health showed that federally qualified health centers (FQHCs) played a pivotal role in enabling equitable access to COVID-19 vaccines for marginalized communities and communities of color. About 61.4 percent of all vaccine doses given at one of the more than 1,000 FQHCs studied went to patients self-identifying as American Indian/Alaska Native, Asian, Black, Hispanic, or “other.”
BMC Health Services Research: (1/12) - Veterans increasingly utilize both the Veterans Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health. This study involved developing a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.
Current Opinion in Pediatrics: (January 2022) - This review summarizes initiatives taken by pediatric health systems to address social determinants of health and recent developments in state and federal health policy impacting funding for these efforts. Despite funding challenges, these initiatives are increasingly common, however value-based payments, expansion of Medicaid funding resulting from policy changes and delivery system reform will be needed to meet the goals of addressing SDOH while supporting financial sustainability.
ASTHO: (January 2022) - ASTHO published a new brief focused on advancing health equity through the legislative process, as part of its Legislative Overview Series: 2022 Public Health Spotlight. The brief outlines legislative trends to address health equity and future state legislative action ASTHO expects states to focus on.
Data and Innovation
Healthcare IT News: (1/18) - Healthcare IT News interviewed Dr. Jim Walton, president and CEO of Genesis Physicians Group about the session he has planned for HIMSS22 on using explainable AI to mitigate SDOH contributors to risk. This interview describes how to avoid pitfalls of applying AI in underrepresented populations and trained machine learning models to the population and data sources to fairly and efficiently identify high-risk members.
Business Wire: (1/18) - NewWave Technologies announced the opening of SAFFRON Labs, an Incubation Hub that will support the creation of the technical capability for a secure consumer-and community-centric, open, interoperable SDOH data ecosystem. SAFFRON Labs will build a modular SDOH Platform to help provide for the standardization of SDOH data collection and build a sustainable, modern technical infrastructure for interoperability between health care entities and community-based organizations.
Health IT Analytics: (1/13) - In 2021, Nemours Children’s Health took steps to improve its data analytics and value-based care strategies, with most of 2021 focused on using analytics and population identification to deliver vaccines to their patients. Nemours is one year into implementing a SDOH screening tool and primary care method for its Delaware operations, which will expand across the organizations.
Forbes: (1/11) - Missing race and ethnicity data make it difficult to appropriately assess the needs of diverse populations that make up our communities, contributing to the continuation of underlying disparities that impact individual health. This article outlines how an equitable data infrastructure is not only vital to improving the health of every person, but also to combatting racism and discrimination.
United Healthcare: (1/7) - The economic impacts of the pandemic increased social needs, but also provided an opportunity for managed care organizations to forge stronger connections with organizations that are experts in addressing those needs. This video shares why data sharing, analysis and collection consistency are critical to improving both member health and member experience.
The Food as Medicine Collaborative in San Francisco is looking to evaluate the impact of their Food Pharmacy program on the clinic staff who coordinate it. Does your organization provide medically-supportive food and nutrition interventions (i.e. produce prescriptions, medically tailored meals, food pharmacies, etc.) and have you received feedback from clinic staff? If so, please reach out to email@example.com