A New Leader for SDOH nยบ3 - Fall1 2020
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Social Determinants of Health Newsletter
NEXT STAGES OF GROWTH Six months ago, we launched the RISE SDoH Community to provide a place for professionals responsible for addressing the social determinants of health to come together to learn, network, and collaborate with one another.
assist with topics for our new user groups.
Since then, we have produced webinars and educational content for our growing community and conducted a virtual version of our Summit on Social Determinants of Health.
For those unfamiliar with her work, Ellen is an author of books, articles, white papers, and knowledge products. Her latest books include, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and The Social Determinants of Health: Case Management’s Next Frontier,, plus the upcoming title, End of Life Care for Case Management.
This month we are excited to enter the next stages of community engagement with the launch of our new SDoH user groups (see p. 4) and the appointment of Ellen FinkSamnick, MSW, ACSW, LCSW, CCM, CRP, a national expert on SDoH, as the non-executive director of the SDoH community.
She is also a panelist for Monitor Mondays and Talk Ten Tuesdays and a contributor to RAC Monitor and ICD 10 Monitor. She also serves as moderator of Ellen’s Ethical Lens™ on LinkedIn, consultant for the Case Management Institute, and moderator of their Case Managers Community.
Ellen will help us lead and shape content for our educational offerings and overall program efforts and
Her academic affiliations include roles as subject matter expert for Western Governors University, and
adjunct faculty for the University of Buffalo’s School of Social Work, and George Mason University’s Department of Social Work. She is also a Doctor in Behavioral Health student at Cummings Graduate Institute of Behavioral Health Studies. We are delighted to welcome her as the lead for our SDoH community and are excited for the future, as our community members work together to create sustainable and scalable programs that benefit our most vulnerable populations. You can learn more about Ellen and her plans for the community on p. 6 and look for her upcoming commentary in this space in our next issue.
Ellen Wofford, Managing Director, RISE Click to see other articles
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RISE ASSOCIATION’S SDOH USER GROUPS RAMP UP FOR LAUNCH The RISE Association is excited to announce the launch of the SDoH Community user groups, which will provide health plans, health care providers, and communitybased organizations (CBOs) an opportunity to network, learn, and collaborate with one another throughout the year. The SDoH Community consists of three separate user groups: health plans, health care providers, and community-based organizations (CBOs). The groups will then come together quarterly for cross-sector collaboration. The interactive, “open-mic” style discussions will take place virtually bimonthly and will be facilitated by hand-selected cross-sectional thought leaders. The user groups are designed as a safe space for peers to discuss challenges, exchange insights and ideas, benchmark best practices, and share lessons learned from firsthand experiences to achieve better outcomes for the most vulnerable populations. Michael 4
Litterer,
CHES,
CPS,
Social Determinants of Health Newsletter
FHELA, director, prevention and recovery, RWJBarnabas Health Institute for Prevention and Recovery, who will moderate the health care provider user group meetings, envisions the user group meetings as a place to move awareness and conversation about SDoH to actionable collaboration. “It’s really now where the rubber is hitting the road. The time of talk is over; the time of action has begun,” he said. The need for collaboration between health plans, health care providers, and CBOs is particularly timely as the COVID-19 pandemic continues to exacerbate SDoH, explained Kevin Moore, vice president of
policy, health and human services, UnitedHealthcare Community & State. Moore will lead the health plan user group meetings alongside Kristin Beck, director, community health program, Health Partners. “We had movement that was happening, but COVID lit a spark that really magnified this. It’s a good evolution that’s forcing conversations about what partnership looks like,” he said. From a health plan side, the user group is an important opportunity to learn and gain appreciation for the network and culture of communitybased partners, explained Moore.
SDOH Health Plan User Group #1 October 13, 2020 CLICK TO SEE UPCOMING USER GROUPS
“As we look at SDoH, it needs to be a bottom-up approach, looking at the resources a community has, the strengths of the community, where we need to bolster,” he said. “You can’t medicalize this. We have to learn to think about it differently.” Jessica Kahn, partner, McKinsey & Company, will moderate the quarterly, Across the Ecosystem, user groups alongside Denise Harlow, CEO, National Community Action Partnership.
The cross-sector user groups will provide an opportunity for health plans, health care providers, and CBOs to come together and put collective brainpower behind focused topics, said Kahn. “I would love for this group to discuss concrete actions that have measurable, quantifiable outcomes.” “My perspective has always been that health care happens outside the doctor’s office,” said Kahn. “I would like to see how addressing SDoH
can improve disparities and remove barriers of inequities we have in our health care system.” Join a user group SDoH community members are welcome to participate in any of the user group meetings. If you have any questions about joining a user group, contact RISE Marketing at membership@risehealth.org.
User group meeting schedule The first user group meeting will be held in October. SDoH community members can participate in any of the user group meetings. All user groups will take place at 1 p.m. EST. Here’s the current lineup for each user group, with additional dates to come: Health Plan User Group: • Tuesday, October 13, 2020 • Wednesday, December 16, 2020 • Thursday, March 18, 2021 • Tuesday, May 25, 2021
CBO/Non-Profit User Group:
Health Care Provider User Group:
• Tuesday, November 17, 2020 • Tuesday, February 23, 2021 • Thursday, April 8, 2021
• Monday, November 30, 2020 • Wednesday, January 27, 2021 • Tuesday, March 9, 2021
Across the Ecosystem Meetings (All user groups): • Tuesday, February 9, 2021 • Tuesday, May 18, 2021 • Thursday, August 5, 2021 Click to see other articles
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MEET RISE’S NEW LEAD FOR THE SDOH COMMUNITY
Ellen Fink-Samnick The principal of EFS Supervision Strategies, LLC, will work with the RISE Association to lead and shape our Social Determinants of Health (SDoH) Community. 6
Social Determinants of Health Newsletter
Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, DBH(s), a national expert on SDoH, will offer RISE content guidance to empower growth of SDoH educational offerings and overall program efforts. She will also serve as the chair of the annual RISE Summit on Social Determinants of Health. Fink-Samnick’s experience with SDoH dates to her first job as a social worker in East New York in the mid-1980s at the cusp of AIDS and HIV. Although the community was once home to a thriving middleto-upper class population, when she began to work there in 1983 the area had rapidly transformed into neighborhoods with an aging population that lived among gang violence, drug users, and poverty. Back then, and like now, she found success bridging the gaps focused on honest discussions with community partners, other facilities, and other professionals about the problems within the community and how they could work together to leverage what they all brought to the table and improve the lives they served. Her career later would take her to Queens Hospital Center, where she ran one of the largest hospitalbased AIDS programs in the New York Metropolitan Area. Like all health care organizations across the country, she worked to address the needs of a poor, disenfranchised, and vulnerable population. Once again, success involved the same approach she used as a social worker: “We sit down, we start talking the same language, we share our challenges, we share our opportunities, and we
brainstorm about where we can access funding,” she said. Those discussions led to her hospital receiving the first Ryan White grant for $500,000 to grow a coalition and interagency clinic to serve a gap in service for AIDS and HIV patients. Eventually, she moved to the metro Washington, DC area, where she worked with patients in that region to address their needs. “Every population I have worked with has somehow been a face of the social determinants,” she said. “If ever there has been a time for every sector of the community to work together and define new ways, new funding, new resources, new program planning, new ways to have interoperability to make it better for the patients and the populations and the communities we serve, the time is now. And I think this community can do that and make a meaningful
...social determinants is now the norm rather than the exception of our health care population”
difference.” Although SDoH has been around for centuries, Fink-Samnick said the hospital industry began to pay serious attention to them when the Affordable Care Act established readmission penalties through the Hospital Readmission Reduction Program in 2012. COVID-19 has now amplified all the gaps and barriers that exist between the “haves and have-nots.” The havenot population has grown bigger due to the pandemic. Millions of people are unemployed, lack health insurance, and face food and housing insecurity. “I would go as far as to say the face of social determinants is now the norm rather than the exception of our health care population,” she said. Despite the challenges, FinkSamnick sees opportunity for improvement because it forces the industry, collectively, to truly address the social determinants. And the SDoH Community, she said, can spearhead the movement. “We can make things happen and create sustainable, value-driven, actionable plans together.”
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7 THINGS TO KNOW There isn’t enough room to list all of Ellen’s accomplishments, but here’s a snapshot of just some of her achievements and why the RISE Association is thrilled to have her join us as the lead of our SDoH community: ENTREPRENEUR She started her business, EFS Supervision Strategies, LLC, in Burke, Virginia, 16 years ago after a long career in social work and case management. The company offers organizational training, mentoring, and consultation services to empower the interprofessional workforce. LIFE-LONG LEARNER Ellen is currently a Doctor of Behavioral Health student with the Cummings Graduate Institute of Behavioral Health Studies. She expects to earn her degree in June 2023. She obtained her BA in Sociology and MSWClinical Practice, School of Social Work from the State University of New York at Buffalo and earned her post-graduate certificates in administration and supervision from the Hunter College School of Social Work. She also holds several professional licensing and certifications, including Board Certified Case Manager, Commission for Case Manager Certification (CCMC); Academy of Certified Social Workers, National Association of Social Workers; Licensed Clinical Social Worker. Commonwealth of Virginia, and Certified Rehabilitation Provider, Commonwealth of Virginia. Her academic affiliations include roles as subject matter expert for Western Governors University, and adjunct faculty for the University of Buffalo’s School of Social Work, and George Mason University’s Department of Social Work. PROLIFIC WRITER Ellen has authored countless articles and several books, including The Essential Guide to Interprofessional Ethics for Healthcare Case Management, The Social Determinants of Health: Case Management’s Next Frontier, and the soon-to-be-released End of Life Care for Case Management. She also is a regular contributor to RAC Monitor and ICD 10 Monitor. SPEAKER EXTRAORDINAIRE Ellen is a sought-after speaker for national conferences. You can hear her regularly through her work as a panelist for Monitor Mondays and Talk Ten Tuesdays. WELL-KNOWN MODERATOR In her spare time, she moderates Ellen’s Ethical Lens™ on LinkedIn and Case Managers Community for the Case Management Institute. AWARD WINNER She is the recipient of numerous awards, including the National Award of Service Excellence (2016) from the Case Management Society of America (CMSA), Distinguished Case Manager of the Year (2002); Case Management Society of the National Capital Area; Distinguished Master Social Work Alumni (2017) University at Buffalo: School of Social Work. SOCIAL MEDIA MAVEN You can follow Ellen on LinkedIn: Ellen’s Ethical Lens; Twitter:@epflcswccm and the Blog: Ellen’s Ethical Lens 8
Social Determinants of Health Newsletter
SDOH SPOTLIGHT
THE IMPACTS OF A CROSS-SECTOR COMMUNITY PARAMEDIC PROGRAM
Chief Derek Bergsten of the Rockford, Ill. Fire Department was a featured speaker at the RISE West virtual summit in September, where he shared the success of a collaborative social determinants of health (SDoH) program that has reduced emergency department visits, ambulance runs, and hospital admissions. Like many communities across the United States, Rockford had a problem with a small group of residents who regularly called 911 for ambulance transport or showed up at the emergency room. Often called ER superusers, super-utilizers, or frequent flyers, these familiar faces typically had multiple health
challenges and relied on the local hospital for care. Derek Bergsten, chief fire officer and chief EMS officer for Rockford Fire Department, the second largest fire department in the state of Illinois, recalled that for several years a group of 15 to 20 people would call 911 on an average of 50 to 60 times a year. “We thought there was something better we could do to improve their overall health, so they don’t have to use emergent care all the time,” he said. Bergsten said the department wanted to think more holistically about these patients and in 2014
partnered with SwedishAmerican, a division of UW Health, on a pilot community paramedic program. “We do roughly 25,000 transports a year and over 50 percent of them go to this hospital. We asked if they wanted to work with us to see if we can have a positive impact on a group of patients to keep them out of the emergency department, riding the ambulance, and being admitted to the hospital. They were on board,” he said. The six-month pilot program included 10 patients and focused on five major issues: Cardiac, COPD, diabetes, recent myocardial infarction, and congestive heart failure. Paramedics initially joined one of the hospital Click to see other articles
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In many cases, the clients didn’t have a support system or family to look after them” nurses and visited these patients in their homes and had them sign a release allowing them to contact their primary care physician. If patients didn’t have a primary care physician, the team would work with the hospital to get them one.
happening in the patient’s home and help connect them to all available resources. “What clients tell their doctor may not be exactly what is going on in the home as far as living conditions and what resources they have,” he said.
“We provided assistance to them, helping them get rides to their appointments, and helping them get their prescriptions,” Bergsten said. They also provided basic education to these clients because they often didn’t understand their health care benefits or how to access them. Community paramedics also conducted home safety checks while they were there and installed smoke alarms and CO detectors, looked for tripping hazards, and checked to ensure the HVAC functioned properly.
By the end of the pilot, patients enrolled in the program had a 70 percent reduction in utilization of 911 calls and emergency room visits. Based on those findings, the hospital CEO said it saved the system more than $800,000.
The in-person paramedic visits lasted an hour or two. Although they initially thought the visits would focus on medical care, Bergsten said they soon realized that the clients needed help with social issues. In many cases, the clients didn’t have a support system or family to look after them. Community paramedics were able to alert the primary care physicians about what was actually 10
Social Determinants of Health Newsletter
The hospital system and Rockford Fire Department soon launched a full-time Mobile Integrated Healthcare Program, which is now in
Chief Derek Bergsten of the Rockford, Ill. Fire Department
its fifth year. The most recent data released by SwedishAmerican shows patients enrolled in the program experienced a 35 percent reduction in emergency room visits, 42 percent drop in ambulance runs, a decline in hospital admissions by 40 percent, and a 93 percent decrease in hospital readmissions. The Department also has an agreement to do similar work with Humana Medicare Advantage patients. Bergsten estimates that in the last five years the program has helped 300 to 400 patients who have Medicare or Medicaid. He credits the success of the program to the fact that paramedics meet with the clients face-to-face and have a relationship built on trust. Bergsten said the two full-time paramedics in the program did have to eliminate the in-person meetings during the COVID-19 outbreak but were able to maintain the relationship by phone because of the fact the clients trusted them and knew the voice at the other end of the line. “One thing we found out when we were looking to enter agreements with managed care organizations, they would have case workers that called the clients. But the clients don’t know them and don’t recognize the number. They think it’s spam, have limited minutes on their phones, and don’t want to answer it. By having that face-to-face visit, coming to their homes, creates a warm handoff. We get them access to other people and they know we are there to help them. So, they connect a face to the phone number. That is one of the largest advantages of this,” he said.
UPCOMING EVENTS
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Geriatric House Calls An Innovative Solution to an Age-Old Problem October 1, 2020 1:30pm Eastern Time
October 27-28, 2020 RISE
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Social Determinants of Health Newsletter