Summer 2019 Volume 1

My favorite place all year round


Welcome to Volume 1 of my Summer 2019 newsletter. You can find past newsletters in my LinkedIn articles and on my website with some additional background materials, different stories and initiatives that might be of interest. Join me in improving and coordinating initiatives that advance health, health equity and community and healthcare redesign.

This month you can read about: Realizing a personal bias; many community transportation initiatives; an introduction to some of the non-health driven community investments; a new health literacy definition; Medicaid directors view on where funding to address social determinants of health should go; Geisinger Food Farmacy; CareSource Job Connect; AHIP’s Project Link; Modern Healthcare articles on the SDoH symposium and Insurers and loneliness; Updating the definitions of ADLs and IADLs; Potential Medicare savings of $4B; United Hospital’s Framework for building Clinical Community partnerships; AAFP wants more consistency and clarity around SDoH terminology; Kaiser’s survey indicates patients want providers to help with social needs; Pilot study on the benefits of home meal delivery programs; Lifting the funding ban on a unique patient identifier; Guiding principles for ethical use of SDoH data; and three data partner initiatives.

Shannah’s Insights

As mentioned in the last newsletter, I’m going with 2 versus 3 newsletters during the summer months. In June and the first half of July, the buzz around living conditions and health as well as the number of partnerships continue to grow. Community initiatives often focus on transportation and the range of initiatives highlight the types of players and programs are expanding.

I am starting my scan of investments from non-health agencies, and programs and provide an overview of some of the agencies and types of programs. However, in the US we don’t have health impact assessments (positive & negative) for policies and programs so it is hard to know what the impacts of the programs are or could be.

I am very concerned about the proposed new health literacy definition that puts the responsibility on “society” to provide accurate understandable information. In the context of Healthy People 2030, it gives plausible deniability to all stakeholders. I don’t love the current definition that appears to put the responsibility on individuals versus the health system and providers, but it has largely been interpreted as requiring better communication by the health care and payment system. The deadline for comments is August 5th. I encourage everyone to comment!

Medicaid directors are reading the writing on the wall, and not unlike long-term services and supports, they don’t want to have sole responsibility for supporting a large and growing population with their social needs in addition to health and LTSS. I think perhaps this cat is too far out of the bag and states will continue to have flexibility in what they choose to do.

Food Farmacy and JobConnect are good examples of where money flows outside of healthcare, my hope would be these programs spin off from their health parents and help more people in the community regardless of who is the insurer.

AHIP’s Project link is a learning collaborative around living conditions and health. It feels like a cautious way to join the movement; however, perhaps they will start advocating for programs and change once their members get more comfortable.

I applaud the call for revisiting the family caregiver job description starting with ADLs and IADLs. Carol Levine has highlighted the importance of the problem, particularly accounting for the complexity, timing, and duration of the tasks. Navigating how these measures are then used to determine the type of help required and a way to acknowledge and support family caregivers, won’t be solved by new definitions, it will also need accompanying policies.

Surveys and research abound, but there are definitely mixed messages and emphasis that make it hard to know what to bank on. Kaiser’s survey results contradict other surveys indicating individuals are not comfortable with their physicians engaging with them about their social needs. AAFP’s recommendations for better and more consistent terminology for living conditions, social determinants, needs and risk factors is a good place to start, but the recommendations that physicians, payers and policy makers agree on standardization first leaves out at least two critical stakeholder groups the research, analysis and programs are seeking to help — the individuals and communities.  To really move up stream we need to have a bigger tent with the many stakeholders outside of healthcare.

Revisiting the funding ban on a unique patient identifier has always been a discussion point for better health data integration. When HIPAA first passed there was swift and strong objection to how such a unique identifier could/would be misused. Today people may be less concerned given all the other trends in identification including the Real ID required to meet increased security standards. However, health and social and economic status information are all highly sensitive and at risk of misuse. Enter the eHI principles for ethical use of SDoH data. A solution I have always preferred would be a voluntary unique ID. For individuals who value the benefits of consistent matching of all their records over any potential risks this would be ideal and help streamline processes and improve data accuracy, perhaps even help us access our own information.

All three industry partnerships or contract announcements are examples of how data on social needs and living conditions are playing a growing role in care delivery.

Lastly, I realize I often defaulted to using SDoH as short hand for living conditions in recognition that I’m swimming upstream and it is usually the term used in the articles and initiatives I’m referencing. Perhaps if there is an effort to standardize the terminology, they will consider using language that can be more readily understood by everyone including the general public.

Share your personal or community stories by connecting via LinkedIn or email I welcome suggestions in all topic areas, particularly community driven models.

A personal story

Confronting our own biases – Two young women from Latter Day Saints came to my door and I planned to quickly say no thanks I’m Jewish. They responded saying they understood, but asked if I needed any help around the house or with every day tasks. I said thank you I didn’t, but we do have a number of elderly couples in the neighborhood who might need some help. I realized I made many assumptions in my plan to quickly dismiss what I thought would be an effort to push their religious views.  Their offer to help in the community regardless of religion was a great discovery that will hopefully have me think twice in the future.

Community Initiatives

St. Lawrence Health System is providing free rides to low income residents for non-medical destinations including: grocery stores, farmer’s markets and self-help classes.

Lyft becomes a certified non-emergency medical transportation (NEMT) provider for Medicaid in AZ.

Home Health Care news highlights the many companies getting into NEMT including Ford’s GoRide, Veyo and Envoy America. The article mentions that homecare companies are also encouraging use of 3rd party transportation rather than providing it as part of their services to address liability concerns.

Background on community investments and initiatives outside of healthcare

Some funding programs that should help address social needs/risks that impact health:

  • Low-income housing is supported by HUD and Treasury programs e.g., the home investment partnerships program and the Community Development Financial Institutions Fund
  • Social Impact Partnership to Pay for Results Act program designed to improve the effectiveness of social services was discussed in February’s newsletter
  • There is a HUD-DOT-EPA Partnership for sustainable communities.
  • There are many types of tax breaks design to encourage investment in low income communities like Opportunity zones that give tax benefits to investors in the designated zones

Most programs design to help low-income and underserved communities however focus on the people not the location. Read more about this in a Forbes article from last year.

Government Initiatives Federal and State (national initiatives)

HHS is seeking comment on a proposed new definition of Health Literacy in the context of Healthy People 2030.

The current definition is: “Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.” While the new proposed definition shifts the responsibility to “society”: Health literacy occurs when a society provides accurate health information and services that people can easily find, understand, and use to inform their decisions and actions.

Inside Health Policy reports the majority of state Medicaid Directors think the best way to tackle social determinants of health is not through Medicaid, but by funding community organizations that work along side Medicaid. Federal funding should fill in the gaps, i.e., provide the funding to the community organizations.

Health System and Community-based Services

Geisinger Fresh Food Farmacy continues to grow as a non-medical means to address uncontrolled type 2 diabetes. Geisinger will have three Farmacies by end of summer and initial results are very promising.

CareSource JobConnect for Medicaid Beneficiaries. CareSource’s case management includes a life coach option. The coaches can help connect beneficiaries with jobs if they opt into the program.

 AHIP announced the launch of Project Link to work on social issues and barriers to care at its annual Institute and Expo. These components are listed on AHIP’s website:

  • A new learning collaborative for insurance providers to discuss emerging issues related to social barriers and social determinants of health.
  • A new Project Link Website, which will spotlight research, insights, and case studies so that insurance providers, community leaders, and consumers can get the best thinking on what’s working.
  • New partnership opportunities for health insurance providers to come together with other organizations to help our communities overcome social barriers to good health.

Modern Healthcare’s summary of Critical Connections: Social Determinants of Health Symposium , Indicates participants wondered how deep of an impact can be made if reimbursement doesn’t soon follow. In another Modern healthcare article the focus is on what insurers are doing for loneliness with CareMore at the forefront with its Togetherness officers addressing loneliness as a chronic illness.

An article about 21st century job description for Family caregiving – says we need to revisit the definitions for ADLs and IADLs “Perhaps, only an entirely new scheme will fully capture the real range of family caregiving tasks.” The article highlights the many ways the definitions are outdated including based on essentially outmoded activities e.g., ability to look up a number (use of the telephone).

Research, Metrics & Technology

Observational Medicare research that looked at the implications of lacking social support for seniors with disabilities suggests billions could be save with additional help in three areas: household activities, mobility and selfcare. Patient Engagement HIT article estimates the absence of these supports drives over $4 Billion in added expenditures.

United Hospital Fund published “A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health”; a report on how to better integrate primary care and social services in urban communities. The framework has four components: Screening for social needs in Primary Care; Developing Primary Care-COB partnerships for effective Social Needs Referrals; Referral Processes in the Real World and Policy Considerations for Social Needs Partnerships. The report concludes the integration will make a significant difference, but still faces challenges including lacking common technology, constrained resources for social services and no compelling ROI.

An American Academy of Family Physicians study seeks greater clarity on SDOH terminology. The article notes there are different uses of terms that can foster misunderstanding. An AAFP news article discussed a range of terms including social determinants, social risk factors, social needs. Some are intended to convey negative impacts, i.e., ‘risk’ while others can influence health in either direction. The article also discusses variation in the context of population health versus individual care and ends with advocating for better clarity among physician, payers and policy makers as perhaps the first step in standardization.

Kaiser sponsored survey indicates patients want their clinicians involved in screening and referring to address social needs. Some noted findings:

  • 93% of Americans feel that their medical provider should ask about access to food and balanced meals;
  • 83% feel that their medical provider should ask about safe and stable housing;
  • 78% feel that their medical provider should ask about social relationships and isolation; and
  • 77% feel that their medical provider should ask about transportation to work, school, appointments, or activities.

A Pilot, studying home delivery meal programs as a means to address unmet needs for at-risk elderly, suggests the programs are helpful in alerting health systems to emerging risks and needs.

Will a unique patient ID be resurrected? The House voted to lift the ban on federal funding for a unique ID. This ban has been in place since shortly after HIPAA was passed. The rationale behind lifting the ban is the same as it has always been better patient matching for data sharing.

eHI issues Guiding Principles for Ethical Use of Social Determinants of Health Data

Signifyhealth announces launch of Signify Community that ties social interventions to quality, satisfaction and outcomes.

Landmark Health and Healthify partner for patient centered chronic care in 13 states

Northwell Health contracts with NowPow to help address SDoH for 1,200 Medicaid patients.

Please share the newsletter and connect via LinkedIn or email with your reactions and input.


Applying Big Data to Address the Social Determinants of Health in Oncology: A Workshop, October 28-29 National Academy of Sciences DC

Background and Definition

I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible.  This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020

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