Summer 2019 Volume 2

Summer’s end and Fall begins


Welcome to Volume 2 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: caregiving realities; the growing role of home care in improved living conditions; ALICE (Asset Limited, Income Constrained, Employed) in Frederick Maryland, an example of a non-healthcare sustained investment in improved communities; USDA and USCIS policies threatening living conditions, providers opposing the USCIS rule while the healthcare industry continues to invest in needed community support; CAN Community health’s LGBT youth mentorship program; Intermountain Health, CVS Aetna and Cedar Sinai continue to expand their efforts; Many studies – one saying few hospitals and physician practices screen for top 5 social needs, another saying the US spending on social services is comparable to other countries, parent focus groups raising concerns about certain pediatric screening questions and AmeriHealth Caritas showing substantial impact on hospital utilization; A NASEM consensus report recommending 5 goals for integrating social care into healthcare; AHRQ announcing 12 semifinalists in an SDOH visualization challenge; and a new BU Community Wellbeing Index.

Shannah’s Insights

Not only does the pace of activity involving living conditions and health continue to accelerate, but so do the numbers of organization, researchers and “reporters” (including me) continue to grow. There is a bit of a counter movement, already saying show us the evidence, but to pretend this isn’t a nascent field would be ludicrous.

I am contemplating how long I will keep monitoring and reporting on this field. For now, my voice is one of the few saying it is a critical and necessary direction, but it should be a growing area of independent investment, not an integrated component of Healthcare. Funding should shift from healthcare to community-based investment, ideally from emerging savings, but initially I would like to see more independent investment that is not tied to clinical health outcomes. This perspective makes me very wary of the Census report on Integrating Social Care into the Delivery of Health Care. I almost feel it should be the reverse.

The trends during the time period covered by this newsletter feels like a roller coaster. There is great innovation, but troublesome concerns and policy actions from other parts of government. The final rule on immigration and US access rule on what constitutes a public charge should have us all concerned.

The growing call for evidence feels premature and will yield results like the study of hospital and physician practice screening that was likely out of date as soon as it was completed in August of 2018! AAFP an early adopter in this growing field launched its screening toolkit in January of 2018 and revised it in October. It is unclear the Hospital industry rallied around any particular tools or surveys.

To counter this research frenzy, I think about Sachin Jain, concept of “radical common sense” understanding people needing, food, rides, housing, employment or a friendly phone call to maintain their health shouldn’t require endless debate and research. When we have enough programs underway, we can debate the timing and need to determine best practices. Some might argue we already have enough valid data on efficacy it is more a question of cost-effective and sustainable delivery of services.

Although our healthcare systems and HHS may be investing in needed living condition improvements, other parts of the government may undercut those investments as is the case with the USDA’s proposed SNAP rule and the USCIS changing definition of “public charge” for green cards and US access. The pediatric opposition to this rule has me wondering if there isn’t an completely different model for pediatrics that should be considered.

The notion that the US all of a sudden invests in social services comparably to other OECD countries is questionable and I felt compelled to include the opposing comment. Yes, we spend too much on healthcare, but that does not mean we spend enough on social services or that investment in social services isn’t part of the cure.

I will end on two positive notes. One, I believe continued recognition of homecare as a critical component of improve living conditions is a needed trend. If investment follows in this adjacent health field, hopefully the field will grow and become a more valued service with more workforce growth and opportunity. Second, I was heartened to learn about the ALICE project, but I wonder how many of the 20 participating states are considering how to put their ALICE efforts at the forefront of advancing social improvement that will in turn advance the health and wellbeing of their citizens.

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

Perhaps caregiving is like death and taxes, inevitable. I have been in the thick of caregiving for the past 2 months and it is not only hard and isolating, but puts you face-to-face with the denial we rely on regarding aging and mortality. Without going into too many details, I found myself 24/7 focused on my husband’s needs when a herniated disk had him incapacitated for 6 weeks before surgery. This was on top of two other chronic conditions. I read, write and think about caregiving for my job every day. I did engage in some caregiving for my parents, but not on a sustained basis.  I was still unprepared for it and thinking that this was 10 years before I should be in this position. I realized the most important thing I could do, to help my husband with a positive attitude, was to have some friends available who let me be sad, angry and frustrated and to take breaks – physical and mental. I have renewed empathy and appreciation for family caregivers who soldier on for months and years.

Community Initiatives

Given the growing understanding that 80% of the drivers of health outcomes are outside of clinical care and that the home and community environment encompasses most of the other drivers, it is not a surprise that more home care companies are embracing the analytics of living conditions the two latest are Senior helpers and Interim Healthcare.

Zing Health is an up and coming physician-led Medicare Advantage plan that addresses social determinants of health (SDOH). The third spin off of Health2047 an AMA investment venture. They see community and home as the new focus of healthcare. Home Healthcare news highlighted “In the view of the founders of Zing Health, the home health and home care industries have been at the vanguard of caring for patients in the setting that is most important in health — the home,”  The CEO went on to say “We believe focus needs to evolve from the hospital being the main focus to the community and to the home,” 

Background on community investments and initiatives outside of healthcare

A local story about Frederick Maryland indicating half of the families in a zip code area near Thurmont were ALICE – Asset Limited, Income Constrained, Employed.

The comparison comes from a newly released interactive tool created by United Way of Frederick County and Frederick Regional Health System. The tool allows people to compare the percentage of ALICE households in areas of the county to obesity, air quality, life expectancy at birth and low food access.

The ALICE project “provides a framework, language, and tools to measure and understand the struggles of the growing number of households in our communities that do not earn enough to afford basic necessities.” It is spearhead by United Way of northern New Jersey and now has 20 state partners advancing the goals of ALICE families having community support and resources to thrive rather than struggle in making ends meet, a win-win for the families and communities.

Government Initiatives Federal and State (national initiatives)

USDA SNAP proposed rule could increase food insecurity among low income families. A recent article on RWJF comments on the proposed rule, discusses the likely negative impact using USDA’s own analysis.

The US Citizenship and Immigration Services (USCIS) final rule on “inadmissibility” for green cards and US access based on public charge grounds – If individuals are not citizens and may seek public benefits including healthcare. Most providers oppose the final rule and believe it will put people at greater health risk due to fear of deportation. Hospitals are particularly concerned that it will just add to uncompensated emergency care. American Academy of Pediatrics also opposes the final rule.  “The National Immigration Law Center said it will file suit to block the final rule.”

A new Bill Social Determinants Accelerator Act was introduced in the House of representatives at the end of July that would make it easier for Medicaid programs to use funds for addressing needed improvement in living conditions.

HRSA awards $35.7 M to 44 orgs to advance improved care for older adults including community-based programs.

Health System and Community-based Services

CAN Community Health in Florida, has developed a mentorship program for LGBT youth ages 13 to 21 and connect them with an adult community health worker.

Intermountain healthcare launches a new company Castell “will leverage Intermountain’s tool and resources to aid payers, providers and accountable care organizations through analytical tools and digital resources addressing virtual care, patient experience and social determinants of health.”

Cedar Sinai LA, CA is providing $15M in grants addressing SDOH for 100 programs in the Los Angeles county region.

The CVS Aetna merged company continues to be proactive in addressing living conditions. CVS launched an SDOH provider network called Destination: Health, it is also competing with Amazon by expanding its Carepass membership to enable $5 monthly or $48 annual fee, free home delivery of prescription drugs and drug-store purchases.

Research, Metrics & Technology

A recently published study, in JAMA Network found that only 25% of Hospitals and 16% of physician practices screen for all 5 major living condition factors – food, housing, transportation, utilities, and interpersonal violence. The survey was conducted from June 16, 2017, to August 17, 2018 and response rates were approximately 47% in each provider category.  

A new study  from Papanicolas et al. highlighted in Health Affairs announces that the US is comparable to other OECD countries in its expenditures on social services. This contradicts what has been understood for years and is getting a lot of traction perhaps in part because it reinforces that the US healthcare expenditures are driven by US healthcare pricing.  The counter argument is presented in the following comment on the article:

“If one appropriately backs out pensions (an income transfer), then the U.S., is far from being “in the middle of the pack” when it comes to social spending as a share of GDP. It ranks near the bottom. Using the authors’ own data provided in the appendix for pensions in the 11 most advanced industrial economies, and backing pensions out of total social spending, I calculate the U.S. spends just 4.4% of GDP on social services. That is less than half its peer group average and far below Denmark (16.5%), France (12.4%) and Germany (10.4%). Only Japan, with 4.1% of GDP spent on social services, is more niggardly to those in need.” Merrill Goozner, Editor Emeritus, Modern Healthcare

Screening for social needs in pediatrics raises concerns for parents as discussed in the Health Affairs article, Screening for social needs; What do Parents Think? The results from 8 focus groups, revealed parents are comfortable with certain question, but questions about domestic violence and the parent’s mental health raised red flags that child welfare services would be knocking at their door.

BU Community Wellbeing index – Boston University School of public health partners with Sharecare to create the index . “Beyond datasets and metrics, the new Community Well-Being Index examines genetics, lifestyle choices and social factors, as well as more than 60 social determinants of health, and real-time and near-time datasets, such as traffic, weather, walkability, food insecurity and crime.”

 AmeriHealth Caritas research on its community health initiatives for Medicaid members shows substantial impact on hospital utilization both admissions and length of stay.

National Academies of Science Engineering and Medicine (NASEM) consensus report Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health “…was intended to examine the potential for integrating services addressing social needs and the SDOH into the delivery of health care with the ultimate goal of achieving better health outcomes.”

The report notes one important question, among others, is “…how to integrate social care (that is, services that address health-related social risk factors and social needs) into clinical practice and what kinds of infrastructure will be required to facilitate such activities.”

The report recommendations are 5 goals that when accomplished will result in better integration of social care.

  1. Design health care delivery to integrate social care into health care, guided by the five health care system activities—awareness, adjustment, assistance, alignment, and advocacy.
  2. Build a workforce to integrate social care into health care delivery.
  3. Develop a digital infrastructure that is interoperable between health care and social care organizations.
  4. Finance the integration of health care and social care.
  5. Fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care practices in health care settings.

The Agency for Healthcare Research and Quality (AHRQ)’s Visualization Resources of Community-Level Social Determinants of Health Challenge recently announced the 12 phase-one semifinalists. The goal of the challenge is to get better data visualization tools for this nascent research focus.

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


The Root Cause Coalition is proud to be hosting the Fourth Annual Summit on the Social Determinants of Health on October 20-22, 2019 in San Diego, California. 

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

Modern Healthcare Social determinants of Health Symposium December 3, 2019, Detroit MI

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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