A pulse check on
Innovative strategies
The virtual RISE
SDoH: Barriers,
SNPs can leverage to
Population Health
funding, and
support individuals with
Summit: A spotlight on
congressional activity
complex social needs
mental health, population
in 2021 and beyond
while advancing health
health in Medicare, and
equity
strategies to enhance efficiency in health care
RISE NEWS
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THE LATEST NEWS
CDC: Number of states with high obesity prevalence nearly doubled since 2018
Report: MA plans need stronger CMS standards, modifications to Star ratings and risk adjustment to truly address social determinants of health
San Francisco launches abstinence-based program for adults in justice system; Stress due to SDoH found to increase risk of heart disease; and more
Low vaccination rates among racial/ethnic minorities stress need for COVID-19 vaccine equity
Gates Foundation 2021 Goalkeepers report: Pandemic drove millions into extreme poverty
Medicare eligibility associated with reduction in racial disparities; Mental health response teams achieve greater outcomes than police; and more
Staggering increase of youth-onset diabetes found among Black and Hispanic children; Aetna, ACES partner to improve quality autism care; and more
Decline in health coverage under ACA for 3 consecutive years amplifies health disparities among racial/ethnic populations
Disadvantaged neighborhoods a key SDoH in older adults’ disability status
CMS’ Physician Fee Schedule proposed rule aims to expand telehealth reimbursement for mental health, improve health equity, patient access
Disproportionate health care spending on white individuals; Depression and anxiety rates doubled in children amid pandemic; and more
Health disparities report identifies persistent, widening gaps in maternal mortality, mental and behavioral health, and food insecurity
3 conclusions from the latest review of SDoH and health outcomes among adults during COVID-19
Climate change as a social determinant; HHS releases new interoperability standards for electronic exchange; and more
Kaiser Family Foundation report: Medicaid authorities and options for states to address social determinants of health
READ OUR ENTIRE COLLECTION OF INSIGHTS AND ARTICLES 2
SDoH COMMUNITY NEWSLETTER
Letter From the Chair
There is a heightened industry emphasis on mitigating food insecurity. This domain has long been a top social determinant of health, though amid the pandemic has become a more urgent imperative. With September closing out Hunger Action Month, I thought I’d take a look at recent findings, innovative initiatives to address the pressing issue, and resources for continued efforts. Nutritional insecurity costs the U.S. economy over $160 billion in poor health outcomes, an amount higher than all state and federal spending on higher education. Food-insecure adults have annual health expenditures of more than $1,800 per person and close to $1,900 per child. Studies by the National Center of Health Statistics have yielded food insecurity
closely tied to increased adverse health outcomes and mortality risk; some 11 percent of persons reporting food insecurity dying over the following decade.
USDA annual food insecurity report’s glaring gaps The U.S. Department of Agriculture (USDA) released its annual report, Household Food Security in the United States in 2020, earlier this month. Data was collected from 34,330 households last December. While 89.5 percent of U.S. households self-identified as food secure, prevalence of food insecurity was found to be rising among households with children, Black Americans, and persons residing in the South.
• The prevalence of food insecurity was higher in Black households (21.7 percent) than white households (7.1 percent). • In households where an adult member was unable to work due to the pandemic, 16.4 percent were food insecure. • Among households with an adult who was either unemployed or prevented from looking for work due to the pandemic, 20.4 percent were food insecure between November and December 2020. • Children in 2.9 million households were hungry, with 8 percent food insecure. A majority of these households had very low food security among children: they were hungry, skipped a meal, or did not CLICK TO SEE OTHER ARTICLES
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eat for a whole day due to lack of money for food. • Fifty-five percent of food-insecure households reported use of one or more of the three largest federal nutrition assistance programs: SNAP, WIC, and the National School Lunch Program.
Communities take care of their own Healthcare organizations are actively partnering with funding entities, community agencies, and programs to bridge the gaps in nutritional sufficiency growing across the population. Here are some of the latest initiatives to hit my radar: • Nourish New York has gained $85 million in investment to date through its four months of funding. The program helps people who are food insecure in NYS access the nutrition they need while offering emergency food providers in the state to purchase agricultural products (e.g., dairy, produce, seafood, eggs) from farmers and deliver it to those individuals in need. • We Don’t Waste, the Denver-based nonprofit, focuses on food recovery efforts by collecting edible food that would have otherwise gone to waste and redistributing it to serve a purpose. The nonprofit works with 165 local partners to collect uneaten meals, foods close to expiration from grocery stores, as well as unused
restaurant ingredients. Donors include businesses, restaurants, caterers, venues, food producers, and institutions. • San Antonio Food Bank and Health Texas Medical Group sponsor Mobile Mercado. This food pharmacy on wheels began as a way to hydrate food deserts, though it’s grown into a sustainable resource providing education on health and nutrition to those in need. Food pharmacies and food is medicine programs are appearing across the country as popular ways to ensure prevention, management, and treatment of dietrelated diseases. If you know of innovative programs focused on food insecurity, share them with Tricia Rosetti so we can highlight them in future articles.
Where’s the money? Along with our current grant funding list, here are a few additional resources specifically focused on food insecurity: • National Sustainable Agriculture Coalition: Community Food Projects: Competitive grants administered by the USDA and National Institute of Food and Agriculture (NIFA). Grants are for eligible nonprofits, tribal organizations, and food program service providers in need of a onetime infusion of federal assistance for projects that promote self-sufficiency
and food security in low-income communities. These one-time grants require a dollar-for-dollar (1:1) match in resources, which can include in-kind support. • Rural Hunger and Access to Healthy Food Listing on Rural Health Hub: Over 20 active funding opportunities are listed to leverage the work of community programs and regional efforts. • Hunger Relief Grants through Dunkin Joy: $1 million in new grants targeting funding-eligible food banks, food pantries, emergency food programs, grocery delivery programs, community gardens, food rescue initiatives, backpack programs, and school-based food programs. Organizations must have 501(C)3 tax status to apply. • Medline Community Impact Grant Program: These results-focused $25,000 grants offer communitycentered solutions and immediate impact. Past recipients have targeted funds for grocery gift cards, mobile food pantries, door-to-door food delivery, and emergency food box shipments for children and seniors. Our SDoH world continues to evolve as does our community of close to 2,000 members! For now, stay safe and take good care!
Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CCTP, CMHIMP, CRP, DBH(s) Social Determinants of Health Community Chair The RISE Association
RISE SDoH Community Exclusive: Funding opportunities targeting social determinants of health
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SDoH COMMUNITY NEWSLETTER
A PULSE CHECK ONº SD H
BARRIERS, FUNDING, AND CONGRESSI ACTIVITY IN 201 AND BEYOND RISE looks at current trends and challenges related to social determinants of health (SDoH) with Melissa Quick, co-chair, Aligning for Health, a coalition advocating to Congress for solutions to address SDoH across the country. For years community-based organizations and social service organizations have implemented innovative ideas that target SDoH locally, particularly in pockets with strong leadership. However, the federal government can help level the playing field and set a foundation for success throughout the U.S. explained Quick, who co-founded Aligning for Health in 2016. “We created Aligning for Health with the idea being that we can be advocating to Congress or working with the administration to highlight best
practices, examples of cross-sector work occurring across the country, and make sure they’re thinking about SDoH and ensuring programs work best together as they’re doing their policy making and thinking about how to best enable communities for success,” she said. Since the start of the coalition, Aligning for Health has worked to eliminate barriers in addressing SDoH through direct advocacy of funding and targeted support for communities and states. Here are a few of the current trends, challenges, and congressional approaches the membership association is seeing:
More health care organizations recognize the impact of SDoH on health outcomes While SDoH and health inequities have always been in existence, they have come
to the forefront in recent years, particularly amid the COVID-19 pandemic. The heightened focus on SDoH and health equity has caused an increased interest in the health care space to partner and build out capabilities to better understand the social needs facing individuals and where inequities are occuring, said Quick. “Over the past couple years, we have noticed there has been a proliferation in health care organizations really taking to heart that SDoH do in fact effect the health outcomes of their populations,” she said, adding that more organizations have started incorporating SDoH into an overarching strategy to determine how to best address the needs of the individuals they serve. At Aligning for Health, the association has been working with the White House administration and Congress to make sure they realize that health care organizations want to establish connections to address social needs and need support at the federal
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level to ensure they can work together to address the gaps.
Data sharing, setting up networks remain significant barriers to addressing SDoH A lack of standardized data and data-sharing capabilities are persistent barriers that interfere with addressing SDoH, explained Quick, not only within the health care sector itself but also between health care organizations, community-based organizations (CBOs), and social service organizations, as most run off different systems, collect information for different purposes, and may not have the capabilities to share that data in an interoperable way. Organizations such as the Gravity Project are working to create and implement standards for organizations to exchange data. “There’s still a lot of room to grow to ensure it can be implemented across the country,” said Quick. The technology gap between health care organizations and non-health care organizations also poses challenges to setting up networks among health care organizations, CBOs, and social services organizations. While a provider may identify that an individual is struggling with a social need and wants to make a referral to a CBO, the provider may not actually have the ability to make the referral and the CBO may not have the ability to receive a referral or loop back with the provider to confirm it can meet the individual’s need. “It’s great that providers are starting to screen more and also starting to refer, but if the food bank the provider Is referring an individual to has no capacity to meet that individual’s need and the provider doesn’t know that, it doesn’t necessarily solve the problem,” she said. There are, however, more attempts and incentives for organizations to fully close the loop with referrals as well as build out actual connections, she added. Development in community information exchanges and tech-enabled solutions, such as Aunt Bertha and Unite Us, are striving to bridge the gap.
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SDoH COMMUNITY NEWSLETTER
COVID led to a spike in SDoH funding, other proposed legislations aim to provide funding beyond the pandemic In the wake of the COVID crisis, there has been a significant amount of funding made available through several COVID relief bills aimed at social needs, such as housing, nutrition, and maternal health outcomes, to build up community level capacity and infrastructure, said Quick. There’s potential for the funding to be made permanent. Over the past couple of years, Aligning for Health has been working with Congress to pass several bills to provide funding for capacity and resources to address SDoH at a local level. “We’re excited to see some momentum here and a lot of interest across both Congress and the administration of really thinking through how to move the ball forward,” said Quick. Some of the recent advancements she shared include: • Parts of The Social Determinants of Health Accelerator Act, a bipartisan bill originally introduced in 2019 and reintroduced this year, were successfully included in the end of year appropriations in 2020, providing the Centers for Disease Control and Prevention with $3 million in funding to establish an SDoH pilot program to award competitive grants to state, local, territorial, or Tribal governments in support of SDoH Accelerator Plans. • In his budget request for Fiscal Year 22, President Joe Biden requested an increase in the SDoH funding from $3 million to $153 million. The House also matched the amount in its Fiscal Year 22 Appropriations Bill, which representatives passed in July. • In June, the House Energy and Commerce Committee held a hearing on health equity and public health data systems, which talked in depth about issues related to social determinants and the solutions needed to address them, as well as the initiative to advance several SDoH bills to further the momentum.
Above: Melissa Quick • The Congressional SDoH Caucus, the first congressional caucus focused solely on SDoH, launched in July. The caucus aims to better understand and highlight best practices of organizations, entities, and governments seeking to address SDOH across the country; the challenges they’re facing; and what Congress can do to help ameliorate some of those challenges and drive improved health outcomes on the ground to proliferate and be scaled to other areas, explained Quick.
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Dr. Angela Huskey on emerging drug threats, the rise in substance use among the elderly riseradio.buzzsprout.com
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5 reasons to register for the virtual RISE Population Health Summit 8
SDoH COMMUNITY NEWSLETTER
For the third year in a row, health plans striving to improve population health efforts will convene to hear more than 20 industry experts’ and thought leaders’ expertise on the actionable strategies that take initiatives to the next level. The live-streaming virtual event, November 16-17, will spotlight critical issues in the population health space; from the dramatic increase in hospital readmissions post-pandemic to maternal health care among vulnerable populations to the mental health crisis, we’re covering it all. As COVID-19 continues to bring pressing population health challenges to light, The RISE Population Health Summit is needed more than ever. The two-day livestreamed event will provide a space for interactive discussion among forward-focused innovators from across population health management to improve efforts and drive change. “I’m so excited for our industry-leading speakers to take the podium and share their expertise and experiences with improving population health for our most vulnerable populations,” said Andrea Kraynak, CPC, senior conference producer, RISE. “With themes running through the conference—from holistic health care improvement to progressive change and enhancing health care efficiencies—attendees should take away a wealth and breadth of new ideas and strategies to help them lead the way in their own organizations and ultimately drive critical change and improve the health of our communities.” The summit will be held virtually November 16-17. Here are five can’t-miss features of this year’s event:
1. A motivational keynote address on leading change Jim Bouchard, leadership activist, speaker, author, and founder of The Sensei Leader movement, will deliver a keynote address on the first day of the summit on leading change through flexibility, adaptability, and comfort with uncertainty. Having transformed his life as a former drug addict to a Black Belt
and now Sensei Leader, Bouchard is an expert on igniting change. Throughout his talk, Bouchard will discuss how to embrace change, find opportunities in uncertain times, and help others grow through change. He’ll also share strategies to connect with all levels of your organization, prevent silos, and communicate effectively, as well as how to build resilience and develop strategies to emerge stronger from a crisis.
2. A timely spotlight on mental health Mental health for many children and adults has taken a toll amid the pandemic. The two-day conference will feature sessions that target the mental health crisis and how to support those struggling. For example, the session, Impact of the Pandemic on Behavioral and Mental Health of Adolescents and Children, will look at how the youth of America have been affected by the pandemic to identify various types of support that will be needed, the long-term impact on the younger population to prepare for changes to health care needs, and the increase on substance abuse, depression, and suicide for this population and how to maximize specialty care to positively improve outcomes. Another session, Virtual Health Care Techniques for Mental Health Patients, will explore the success of implementing virtual health care services for patients with mental health issues and how you can incorporate the services into post-pandemic care. Attendees will learn the benefits of virtual group therapy over in-person group therapy and how patients benefit from the new approach, how to overcome issues related to reimbursement for virtual care by implementing tried and tested best practices, and best practices for technology education for patients who need assistance to receive virtual care.
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3. A look at population health in Medicare Population health in Medicare is a key content theme throughout this year’s summit, with sessions featuring: Rafael Gonzalez, Esq. partner, Cattie & Gonzalez, PLLC, will analyze the impact of COVID-19 on Medicare claims by diving into COVID-19 cases, hospitalizations, deaths, medical impairments, and health care costs within the Medicare beneficiary population. He’ll compare data sets from pre- and post- COVID to comprehend statistically significant numbers in the early and late cycles of 2020 COVID-19 and the impact on Medicare members, as well as the differences in health care based on geography, cases, hospitalization, discharge, conditions, and payments to identify which populations were most impacted. A panel from UH Population Health will discuss how to transform your Medicare Shared Savings Program (MSSP) to improve patient outcomes. The panel will offer a step-by-step guide to success when transforming your MSSP to achieve your operational goals, how to prepare for changes to your infrastructure and personnel to achieve the end goal of improving patient care, and the new tools that can be created and implemented to streamline your operational processes.
4. Tried-andtrue strategies to enhance efficiency in health care The conference will feature several sessions focused on enhancing efficiency in health care. The sessions will focus on: • Strategies to engage with hard-toreach members, including how to identify members who are challenging to reach, how to develop a plan to increase interaction with these members, opportunities to avoid costly long-term health care issues, and advertising techniques to reach rising risk patients. • Strategies to improve access to digital health and intelligence, such as new approaches to improve technology 10
SDoH COMMUNITY NEWSLETTER
literacy within your membership to improve health outcomes, partnership opportunities with providers to help identify members who have difficulties with accesses to digital health or need support, and actionable plans to roll-out technology literacy training to all populations. • Critical actions after hospital discharge to reduce readmission, including the essential steps that need to be taken as soon as patients are discharged from the hospital to impact their health care needs; a plan of action for communication, support, and guidance to reduce the probability of readmission; and how to determine the steps taken based on individual patients to create an understanding of specific needs based on different populations.
“...Strategies to improve access to digital health and intelligence, such as new approaches to improve technology literacy within your membership...”
5. Virtual networking opportunities with industry leaders and fellow attendees While the conference is virtual, attendees and speakers will still enjoy ample networking opportunities in RISE’s exclusive networking lobby. Participants will be able to turn on their cameras, hop around to virtual roundtables, and enjoy face-to-face interactions while connecting with attendees, speakers, and solution providers. There will be four networking sessions throughout the two-day event, including two networking breakfasts, a networking lunch, and an evening networking reception.
Click here to learn more about The RISE Population Health Summit, including registration, full agenda, and list of speakers.
5 WAYS SNPs CAN SUPPORT SPECIAL NEEDS POPULATIONS WITH SDºH PROGRAMS TO DRIVE HEALTH EQUITY Learn about the innovative strategies special needs plans (SNPs) can leverage to support individuals with significant, complex social needs while advancing health equity.
programs and drive health equity and social justice.
SNPs are in a unique position to address social needs as well as drive health equity and social justice through a strategic model of care. Most Medicare Advantage (MA) plans provide benefits related to fitness, dental, vision, and hearing. But far less provide benefits that meet deeper social needs such as meals benefits, transportation, bathroom safety, and in-home and caregiver support, which is where SNPs really shine, according to Eve Gelb, senior vice president for member and community health, SCAN Health Plan, who presented at RISE’s virtual Special Needs Plan Leadership Summit in June.
Data collection is critical to understand the needs of a population and adapt your model of care, explained Gelb, who recommended plans use Health Risk Assessments (HRAs) to collect not only SDoH information but Race Ethnicity and Language (REAL) and Sexual Orientation Gender identity (SOG) data as well.
During the presentation, Gelb shared the key elements of a SNPs’ model of care that enable it to address social needs
1. Collect the right data, in the right way
While there is an abundance of accessible clinical data, Gelb recommended plans prioritize data around self-efficacy, social situation, and function and cognition. Most importantly, when collecting data from individuals, be sure to collect it in a way they are willing to share. Gelb recommended plans ensure they always give members a ‘prefer not to answer’ CLICK TO SEE OTHER ARTICLES
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option as well as an option of who they want to share their data with.
to address outcomes driven by “past failures” of the health system, said Gelb.
to them, as well as obtain sustainable revenue sources.
2. Conduct intensive complex care management
She recommended plans remove this barrier by acknowledging those past failures, such as unethical care and institutionalized and structuralized racism, and providing trustworthy staff to earn the trust of members and commit to actively antiracist and just health care. Plans can then drive change by establishing purposeful frameworks focused on health equity.
To gauge the current status of CBO and health care partnerships the last few years, the Aging and Disability Business Institute conducted three Requests for Information surveys between 2017 and 2020, which Scala-Foley shared results from during the presentation.
Plans should also direct the same kind of focus toward their workforce, she said, by decreasing institutionalized racism and ensuring they have good benefits. “If we don’t care for the population who serves our members, who are representative of our members, then we can’t address the needs of our members,” she said.
The number of CBOs that participate in contracts with care entities has steadily increased year over year since 2017.
Intensive care management is a large part of what many SNPs do to support social needs. In addition to medical needs complex care management, SNPs have an opportunity to provide intensive in-person complex care management by leveraging resources such as social workers, community health workers (CHWs), nurses, and pharmacy technicians to address intense social needs. “It’s not just about a referral to a community resource but the actual work that’s required to meet the need,” said Gelb, noting the hands-on approach can look different based on the individual’s need. “It’s about resolving evictions, going to family court with these folks, really supporting people experiencing elder abuse to get to safe environments, not just making an APS [Adult Protective Services] referral.”
3. Provide linguistically and culturally appropriate transitions of care Once SNP members are ready to engage with more intensive services, plans can offer benefits such as in-home care as well as in-person linguistically and culturally appropriate care transition, typically through a CHW, to support a transition of care and then develop rapport and engage with the member, explained Gelb. CHWs serve as linguistically and culturally competent resources who understands the needs a population faces and how to create a culturally relevant treatment plan. The role of the CHW “really supports engagement with a health system that is not designed to meet the cultural and social needs of the folks we work with.”
4. Remove barriers and drive change Since SNPs typically serve underserved populations, the plans are frequently left 12
SDoH COMMUNITY NEWSLETTER
“Regardless of the step along the model of care, SNPs have really been integrating social needs into the model of care in a way that is not just about the benefits but it’s about the resources,” said Gelb, crediting SCAN Health Plan’s care model for the plan’s ability to address health equity head-on.
5. Forge communitybased partnerships Community-based partnerships are important for everyone involved–health care providers, payers, and the community-based organizations (CBOs), explained Marisa Scala-Foley, director, aging and disability business institute, National Association of Area Agencies on Aging, who presented alongside Gelb. For health care providers and payers the partnership provides an emphasis on the integration of health care and social services, increases recognition of the importance of services that address SDoH and community living services for health outcomes, and contributes to the drive toward value-based care. The partnership also provides CBOs with an opportunity to increase the recognition of the value they can bring to health care partners in improving health outcomes and quality of life, engage individuals, their families, and communities on what matters
A few of the insights she shared include:
• The five most common services CBOs are providing under contract include ongoing case management/care coordination/service coordination, evidence-based programs, nutrition programs, transitions from hospital to home, and home care. • The three most common health care payer partners for CBOs with contracts include Medicaid managed care plans, state Medicaid plans that are not a pass through via a managedcare organization, and commercial or employer-sponsored health insurance plans. • The three most common health care provider partners for CBOs with contracts include hospitals or health systems, Veterans Administration Medical Centers, and accountable c organizations/health homes. As for best practices in successful partnerships between CBOs and health care entities, Scala-Foley emphasized the value in finding the right partners with a shared vision, mission, and language; openness and flexibility; culture change in both sectors with buy-in at all levels; integrated, efficient workflows; adequate infrastructure; and clearly defined and open data-sharing protocols.
UPCOMING EVENTS The RISE Population Health Summit November 16-17, 2021 A Live-Streaming Virtual Event
SDoH User Group (Meeting 4) November 16th, 2021 at 1:00 pm EST
Women in Health Care Leadership Summit December 14-15, 2021 Manchester Grand Hyatt Hotel, San Diego, CA
RISE National 2022 March 7-9, 2022 Gaylord Opryland, Nashville
The RISE Summit on Social Determinants of Health March 20-22, 2022 The Omni Nashville, Nashville
Medicaid Managed Care Leadership Summit April 26-27, 2022 A Live-Streaming Virtual Event
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Ilene MacDonald Editorial Director imacdonald@risehealth.org
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