RISE NEWS nยบ5 - Winter 2021
A LOOK BACK ON 2020 The year of COVID-19 and its impact on the social determinants of health
THE LATEST NEWS SDoH partnership: Independence Blue Cross and Signify Health to launch community health network
Social determinants in the news: AMA adopts new policies to address SDoH; Cardiovascular death linked to food insecurity; and more
Equality Health integrates SDoH efforts in primary care practices to improve care delivery
SDoH programs aim to address Medicaid members’ social needs
New report proposes to include individuals with social vulnerabilities in first round of COVID-19 vaccine
Health Care Futurist Ian Morrison named keynote for RISE National 2021
SDoH and diabetes: American Diabetes Association unveils scientific review on risks and outcomes
How to finance SDoH initiatives for children, a critical step to their wellbeing and health
2020 Survey of America’s Physicians: COVID-19 Impact Edition results underscore focus on SDoH
The unintended consequence of social distancing on older adults
SDoH in the news amid COVID-19: Loneliness rates double in adults; communities of color suffer disproportionate financial strain; and more
Financial and Overall Health are Deeply Connected: How Accurate Data Can Improve Outcomes
FOX Rehabilitation
TransUnion Healthcare
READ OUR ENTIRE COLLECTION OF INSIGHTS AND ARTICLES
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SDoH COMMUNITY NEWSLETTER
Letter From the Chair A LOOK BACK ON
THE YEAR OF COVID-19 AND ITS IMPACT ON THE SOCIAL DETERMINANTS OF HEALTH 2020 in the social determinants of health (SDoH) space began with the same priorities of past years: • Bridge the disparities prompting escalated health care utilization and costs • Develop programs that get to the root of these costs, and long-standing barriers to care for the marginalized persons and populations • High levels of mergers and acquisitions continued in 2020, forging cross-sector collaborations that addressed gaps in health and behavioral health. Then came COVID-19. While the virus has touched every population, those already at risk of disparities are experiencing unprecedented impact.
COVID-19 SDoH priorities Emergent priorities have appeared:
• Pediatric populations face profound disparities: 1:5 children live in poverty, which puts them at greater risk of developing costly chronic illnesses such as asthma and diabetes. • Unemployment, courtesy of layoffs, furloughs, reduced work hours, and business closures have prompted a dramatic rise in Medicaid recipients, an 11.3 percent increase in managed Medicaid from March 2020-September 2020 alone. • The “now you see it, now you don’t” eviction moratoriums have created record numbers of homeless persons and families. • Expanded attention to the social determinants of mental health (SDoMH) due to concerning exacerbation of behavioral health issues, substance use, and suicidal ideation.
While the virus has touched every population, those already at risk of disparities are experiencing unprecedented impact.
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» Rising prevalence of family violence (whether child or adult abuse), domestic violence and sexual assault, by as much as 80 percent. Safer at home is not a reality for all persons. » A ripple effect for older adults, people of color, those persons with low income and living in residential facilities. » The intersection of COVID and addiction, with program disruption negating access to services and treatment options. • Despite regulatory and payer attention to assure reimbursement for telehealth, the digital chasm remains . Poor, limited, or insufficient Wi-Fi access remains a challenge across urban and rural areas especially.
Model programs In the scope of the SDoH, I’ve long touted that, “communities take care of their own.” Efforts demonstrating the greatest rewards are those entities with actionable impact for defined population(s). Among those efforts to watch moving into 2021: • Robert Wood Johnson Barnabas’ Health Beyond Hospital Program, a cross-sector collaboration that screens every patient for SDoH conditions, refers and connects them to community services, and provides ongoing support • The Homeless Outreach Medical Services (HOMES) program , a collaboration between Parkland
In the scope of the SDoH, I’ve long touted that, “communities take care of their own.” 4
SDoH COMMUNITY NEWSLETTER
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Hospital in Dallas, Texas, and the Children’s Health Fund Highmark Blue Cross Blue Shield of Delaware collaboration with FindHelp.org (formally Aunt Bertha) to assure beneficiaries at risk of the SDoH have direct access to resources Cigna Medicare Advantage expansion of programs to address the social needs of beneficiaries CareSource’s JobConnect platform links members with employment, offering education and skill building programs The partnering of Centene subsidiaries with community-based organizations to provide access to food and other essential supplies across the states BEAM: Black Emotional Mental Health Collective Recent AHRQ grants winners focused on rural postpartum mental health:
...continued emphasis on integrated care, plus health literacy will be on everyone’s wish list for the coming year.
» $50,000 cross-sectional innovation prizes for St. Peter’s Health in Helena, Mont. for its maternal mental health program that identifies at-risk individuals and connects women to resources and appropriate care early in pregnancy; and Pack Health in Birmingham, Ala., for a digital health coaching program to address postpartum depression » $25,000 prize to Massachusetts Child Psychiatry Access Program for Moms, Flathead County, Montana’s Postpartum Resource Group, and the Art Heals: Wellness Workshops for Postpartum Women program from Oregon
What will 2021 bring? Experts note cross-sector collaborations, programs to leverage social informatics, and continued emphasis on integrated care, plus health literacy will be on everyone’s wish list for the coming year. What else? RISE’s new SDoH Community and upcoming Summit on SDoH will keep you all informed on the latest happenings. For now, have a healthy, safe, and enjoyable holiday season!
Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CCTP, CMHIMP, CRP, DBH(s) Social Determinants of Health Community Chair The RISE Association
COVID-19 escalates opioid epidemic and other addictions, intensifies mental health issues Research indicates a concerning increase in relapse, fatal and non-fatal overdose, anxiety and depression, and other mental health conditions due to the pandemic. Social isolation, unemployment, and financial insecurity are just some of the stressors riddling individuals and families as the nation struggles to manage virus spread and economic downturn. The impact of COVID-19 on addiction and mental health was a paramount discussion throughout RISE’s recent virtual Population Health Summit. During the live-streamed conference, Anthony Rizzuto, LMSW, CASAC, CAI-I, director of provider relations, Seafield Center, shed light on how the pandemic has escalated substance abuse, increased relapse and overdoses, and exacerbated mental health, domestic violence, child abuse, and so much more. “In my lifetime, I’ve never seen anything anywhere near what COVID-19 has done,” said Rizzuto, an ARISE certified interventionist who has worked in the field of addictions for almost 20 years. CLICK TO SEE OTHER ARTICLES
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The impact of COVID-19 on addiction
When individuals have an increase in stressors in their lives and don’t have the necessary coping mechanisms to deal with them, it’s common to turn to drugs and alcohol as a solution to the problem, explained Rizzuto. Due to the amount of life stressors that have multiplied immensely due to COVID-19, people are having a much more difficult time achieving abstinence and sobriety. That population includes those who have had a substantial amount of sobriety in their lives, said Rizzuto, who saw this firsthand when his client, who was previously sober for 30 years, was admitted as an inpatient due to a relapse. The problem is compounded by hospitals that had to close rehabilitation centers and detox services to increase bed availability, and the closure of selfhelp groups, gyms, and other resources and outlets that people rely on to help with their abstinence and sobriety. Rizzuto has also seen more and more individuals who have not used before but are now turning to substances like
alcohol or pills as an option because they work from home and don’t have to drive or go into an office. With the increase in relapse and substance abuse, there has also been a significant jump in fatal and non-fatal overdoses, most commonly opioid related. A recent analysis released from the White House found overdose deaths were up 11.4 percent from January to April this year when compared to the same period in 2019.
The impact of COVID-19 on mental health
Mental health also continues to take a significant toll throughout the pandemic. “People who have mental health diagnoses, it’s escalated, and people who didn’t have diagnoses are now showing signs of anxiety and depression,” said Rizzuto. He noted the following statistics to illustrate the depth of the problem: • A 31 percent increase in anxiety and depression compared to the same time of year in 2019 • A 20 percent increase in trauma and stress • An 11 percent increase in suicide rates
“Due to the amount of life stressors that have multiplied immensely due to COVID-19, people are having a much more difficult time achieving abstinence and sobriety.” 6
SDoH COMMUNITY NEWSLETTER
Furthermore, one in four Americans between 18 and 24 years old say they have considered suicide in the past month because of the pandemic, according to the Centers for Disease Control and Prevention. The increased isolation has been especially difficult among children and young adults. “There is absolutely something happening in the lack of socialization for kids, especially younger kids who haven’t been able to develop coping mechanisms,” said Rizzuto. “This week alone, I received four phone calls from parents of young people between age 14 and 17.” Marital discord is also one of the many impacts of COVID-19. Couples are now home together 24/7, dealing with unemployment, financial issues, death of loved ones, illness, homeschooling children, and mental illnesses, said Rizzuto, who shared recent research that indicates 31 percent of couples report the quarantine has been damaging to their relationship. Due to the increased time at home as well as the increase in stress from social, economic, and psychological factors, the number of calls and reports of domestic violence and child abuse have also spiked. More people are unemployed or working from home, and children are
home from school, leading to close contact to the victim and the abuser, limited opportunities for the victim to escape abuse, and increased isolation from any supports. The use of drugs and alcohol also increases the risk and severity of abuse, he explained.
Support for mental health and addiction during COVID-19
Rizzuto provided key tactics for clients to find a healthy way to cope and feel more in control during COVID-19: • Maintain a semblance of “normal routine” • Try to move forward with pre-COVID life plans as much as possible • Be present in the moment and try to avoid worrying about the future • Maintain relationships with friends and family • Set reasonable expectations • Reach out for help The American Medical Association has also requested governors and state
legislatures adopt the new Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) rules and guidance for the duration of the national emergency. These recommendations include: • Flexibility for evaluation and prescribing requirements using telemedicine • States must enact as part of their own Emergency Orders and other actions a complete removal of prior authorization and other administrative barriers for medications used to treat opioid use disorder • States must remove existing barriers for patients with pain to obtain necessary medications, including removing arbitrary dose, quantity, and refill restrictions on controlled substances • States must enact, implement, and support harm reduction strategies, including removing barriers to sterile needle and syringe services programs
“...number of calls & reports of domestic violence & child abuse have also spiked”
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7 STRATEGIES
TO IMPROVE CARE DELIVERY BY ADDRESSING SOCIAL DETERMINANTS OF HEALTH
Addressing social determinants of health (SDoH) has enabled one special needs plan to improve health outcomes for members and has led to a decrease in emergency room visits, inpatient admissions, and inpatient lengths of stay.
environmental factors, play a critical role in individual and population health, and addressing issues such as food and housing security, access to transportation, education, and literacy, can make all the difference, explained Mihale.
Dennis Mihale, M.D., chief medical officer, Upward Health, recently presented a session at RISE’s virtual Special Needs Plan Leadership Summit and shared the strategies Upward Health, a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs, has implemented to address SDoH.
“Social determinants of health really is an opportunity to move the needle,” he said. “These factors may be more important than what we might deliver in an office.” In fact, 80 percent of health outcomes are related to physical environment, social determinants, and behavioral factors, noted Mihale, whereas only 20 percent of health and wellbeing is related to access to care and quality of services.
SDoH, which include a broad range of personal, social, economic, and
Although individuals with special needs can be especially difficult to engage in the health care system to coordinate care, Upward Health has discovered key strategies that have made a significant difference in how they address SDoH and their care delivery as a whole. Indeed, by addressing SDoH, Upward Health saw a 42 percent reduction in total acute care days resulting from a decrease in emergency department visits, inpatient admissions, and inpatient lengths of stay. In his presentation, Mihale shared operational best practices for special needs plans to best address SDoH:
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Develop a relationship of safety and trust
Patients must be able to trust who they work with, whether it’s with a nurse, doctor, social worker, or community health worker. “The number one driving force of good outcomes is developing a relationship of safety and trust. When they develop that relationship, things change. The needle starts to move.”
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Be proactive
Addressing SDoH is high-touch and it requires frequent communication with patients. “This isn’t seeing a patient once a quarter, not even once a month. It’s high-touch and it’s expensive, but we leverage a lot of less-expensive but powerful resources.”
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Address adverse childhood events
A huge roadblock to addressing SDoH can be adverse childhood events, noted Mihale. “It leaves scars and trauma, and until you address them you may have trouble engaging the patient and therefore have a problem delivering the best possible care.”
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SDoH COMMUNITY NEWSLETTER
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Let patients tell you their needs
Too often, providers will try to tell patients what their needs are, but there’s more power in listening, explained Mihale. Give patients the opportunity to define their own needs and share what they would like to address.
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Leverage community resources and build partnerships
A great method to improve patient outcomes and reduce costs for highrisk, high-need patients is to identify gaps in care and then partner with community resources that can fill those gaps, such as local community-based organizations, housing authorities, or community health workers.
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Address mental and behavioral health issues
If a patient struggles with mental or behavioral health, it cannot be ignored. Taking on issues such as addiction is extremely tough, but vital, , explained Mihale. “If you cannot address it, find someone who can.”
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Practice poverty simulations
If you can’t relate to poverty, it’s important to execute a poverty simulation for executives and staff to understand the realities and challenges faced by low income families. The simulations not only raise awareness but also highlights SDoH, stereotypes, and the responsibility of the community.
Dennis is the Chief Medical Officer, responsible for development and oversight of the company’s clinical programs and the clinical team, with focus on promoting the best outcomes, the highest member satisfaction and the most appropriate costs of care. He brings with him 20+ years of experience in healthcare technology, MA Risk Adjustment, HEDIS, MLR management, physician documentation and clinical governance.
HOW PROGRAMS TO ADDRESS SOCIAL DRIVERS OF HEALTH ARE RESPONDING TO AND LEARNING FROM THE COVID CRISIS The COVID pandemic changed the landscape of the social needs that drive health overnight. Millions of people lost their jobs; millions of people were ordered to stay home. People lost access to food for themselves and their families because they couldn’t afford it, or they couldn’t get to a grocery store. Miles of cars waiting at drive-through food pantries dominated the headlines. People became more isolated and depressed. People’s ability to pay for their housing was jeopardized. This brief describes how three organizations already versed in addressing social drivers of health pivoted fast to respond to this enormous increase in social needs. Within weeks, leaders from Humana, UnitedHealthcare, and Second Harvest Heartland redesigned – in some cases radically, in other cases
incrementally – their member interactions, programs, and operations. While very different in many ways, these organizations are pursuing a common mission and have developed similar strategies to fulfill it – historically, and during this crisis. Humana’s “Bold Goal” program collaborates with social service organizations in 16 communities to address food insecurity and loneliness. Second Harvest Heartland’s “FOODRx” program in Minnesota works with health care payors and providers to provide home-delivered “medically tailored” food boxes to people with chronic conditions. It also connects them to other vital food resources and assists with SNAP (food stamps). UnitedHealthcare’s “Accountable Health Communities” program in Hawaii works with hospitals and health centers to
screen patients for social risk factors and refer them to community resources. In a forum sponsored by Harvard Kennedy School in June 2020, the programs’ leaders outlined what they did, what they learned, and how they expect their programs to evolve. In a word, they had to pivot – not once, but several times – to meet their patients’ needs. In a compressed timeframe, emergency response evolved into more systematic program modifications as these organizations learned more about what their members needed. The three programs’ strategies and responses followed similar paths. In addition, all three leveraged the relationships, tools, and skills they had refined since the inception of their programs. CLICK TO SEE OTHER ARTICLES
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EXISTING PROGRAMS WERE MODIFIED TO MEET IMMEDIATE NEEDS. All three organizations quickly expanded and modified their food distribution to meet enormous surges in demand. FOODRx began delivering nutritious food boxes to homebound seniors and developed partnerships with transportation vendors to take people to the grocery store and/or food shelves. Humana set up drive-through sites in stadiums and parking lots. In addition, Humana redirected the volunteers who were visiting older adults to combat social isolation to do their grocery shopping.
VIRTUAL COMMUNICATION REPLACED IN-PERSON VISITS. All three programs screen patients for social risk factors like food insecurity. They quickly transitioned to phone and other virtual communications – similar to providers’ massive shift to telehealth. Humana created a proactive outreach team to contact their high-risk members. The care coordinators at FOODRx’s health care partners added questions about food insecurity to their conversations with patients. UnitedHealthcare’s social service partners figured out how to help people fill out SNAP applications using virtual communication tools.
FORMAL AND INFORMAL DATA ANALYSIS IDENTIFIED THE GREATEST NEEDS. All three programs drew on their established data sources – including patient screening results, health records, call center statistics, and anecdotal information from the field – to figure out where demand for services was growing and where the unmet needs were greatest. For example, UnitedHealthcare added new questions about COVID-related support to its screening questionnaire. They also used the aggregate screening results to understand how needs for food, housing, transportation, and other services were changing.
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SDoH COMMUNITY NEWSLETTER
THE CRISIS INSPIRED RAPID RESPONSE AND DECISION-MAKING. All three programs highlighted the speed and agility of their organizations and partners. Decisions that would usually take months were made in weeks – to modify programs, set up new communication channels, redirect staff and volunteers, and increase funding. Everyone pitched in regardless of title or job description. These programs already operated in an agile “test and learn” mode -- a strong foundation to move quickly and effectively to meet unprecedented needs.
FUTURE DIRECTIONS. These programs gained new insights into their members’ needs and the options to meet them where they are. Going forward, they expect to sustain innovations like virtual visits and grocery delivery to homebound older adults. In addition, they expect to study the impact of their COVID responses on the extraordinary needs they were designed to meet.
About the author Alexandra Schweitzer specializes in the design, development, and leadership of integrated health care payment and delivery systems, including programs to address social drivers of health. Recent highlights of her work as an organizational leader and consultant include building and serving as Executive Director for a five-star Senior Care Options program for dual-eligible seniors; and collaborating on the design, implementation, growth, and SDOH strategies of two Medicaid ACOs. Alexandra is a Senior Fellow at the Mossavar-Rahmani Center for Business and Government at Harvard Kennedy School. Bridging her leadership experience and academic rigor, her research focuses on success strategies for programs to address social drivers of health. She welcomes contact at aschweitzer@hks.harvard.edu. Alexandra has served on numerous non-profit boards in senior living and home care. She is currently Board Chair of Goddard House Assisted Living. As a member of the LeadingAge Massachusetts board, she founded an innovative Housing + Health Integration workgroup. Alexandra has a Master’s in Public Policy from Harvard Kennedy School, an executive MBA from Columbia University, and a BA in English and American Literature from Brandeis University.
UPCOMING EVENTS Health Care Provider User Group January 27, 2021 at 1PM EST
CBO / Non-Profit User Group February 23, 2021 at 1PM EST
The RISE Summit on Social Determinants of Health
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March 28-30, 2021
RISE National 2020 March 28-30, 2021
Medicaid Managed Care Leadership Summit April 27-28, 2021 A Live-Streaming Virtual Event
The Special Needs Plan Leadership Summit June 22-23, 2021 A Live-Streaming Virtual Event
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