December 2021 Newsletter


Welcome to my December 2021 Living Conditions and Health newsletter. You can find past newsletters with additional background materials, and different stories and initiatives on my website and in my LinkedIn articles or posts. Join me in identifying and coordinating initiatives that advance health, health equity and community and healthcare redesign.

Shannah’s Insights and Reflections

It is the season of predictions and I marvel at how so many organizations and individuals still seem inclined to make predictions after living through the unprecedented and unpredictable past 2 years. I will take my prior stand of stating my hopes for the coming year that could be within our collective capabilities.

  1. The pandemic becomes the needed wake up call for our country and the world to approach life and humanity as the fragile gift that it is.
  2. All people living in the US have access to resources and services that enable living conditions that are secure and circumstances in which they can have a “fair and equitably opportunity to live” (borrowed from the Tulsa article below).
  3. Our country’s commitment to health equity and the elimination of structural racism will be codified in laws and programs so that there is no going back.
  4. Healthcare access is recognized as a right and all healthcare providers are supported to enable needed equitable access.
  5. Politics return to civil discussions that make the rights and needs of all Americans the driving priority.

Sadly, or perhaps by necessity the Omicron variant has put us all back in the realm of uncertainty and inequity as many struggle to get tested, to get results, to avoid unknowingly infecting friends and family.  The good news is it is proving to be milder for most people testing positive. The New York times reported US deaths have passed 800,000 and cases rose above 50 million. The impact of the pandemic continues to disproportionately affect people of color and underserved populations. The response to the pandemic is our daily reminder of how politics in many states are ignoring the stark realities of the pandemic. Let’s hope we see an improvement in 2022.

This Medscape article about an anti-racism and cultural humility nurse training program could be a model for all organizations seeking to fundamentally change inequities that are woven into existing relationships and interactions. The three factors of the program below and the tenets of the cultural humility are worthy goals for everyone in healthcare and arguably all industries.

a. Focusing on the self and collective image

b. Grounding the training in the context of US race relations history

c. Building the capacity of the institution to “doggedly pursue equity”


A. Nurturing a lifelong commitment to self-evaluation and self-critique

B. Redressing power imbalances in the patient–clinician, educator–student, colleague–colleague, and academic center–community dynamics

C. Developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities

D. Stewarding an organizational-level developmental process that’s ongoing

Cheyenne Regional Medical Center’s approach to its community health needs assessment is another worthy model. The survey process resulted in the following 3 Social Determinants of Health (SDOH) considerations that create current health needs and will be the focus of the coming three-year program cycle:

  1. Neighborhoods and Physical Environments, things like housing, safety, and transportation.
  2. The Healthcare System, do people have access to quality and culturally competent care?
  3. And Economic Stability, do people have employment, sufficient income, and financial security.

A Medscape article discusses the reality of rural health/death disparities due to rural hospital closures. It is a critical reminder that we need better rural alternatives. Rural hospital closures were higher in 2021 than they have been since 2005. With technology and mobile services there should be guaranteed timely services. Perhaps this could be part of the Build Back Better legislation, although the viability of the passage for the Act is unclear.

An article on Tech being the next SDOH, is written by a tech entrepreneur with a platform for a Medicare plan targeting tech for older adults. Although I would say tech has and will continue to be an SDOH starting with the digital divide and access to broad band, this article and others that focus on any one SDOH all need to consider the amplifying affect of tech challenges and multiple SDOH considerations. The most successful programs to support improved living conditions partner with community organizations and programs and ensure that access is not solely reliant on technology. If tech is the primary access point, then there must be community navigators and people interfaces, not just APIs, who will navigate on behalf of those without access in an ongoing manner. A glaring example is the problem of access to COVID testing and vaccines that rely on smart phone technology!

Fewer people in the US believe there are health inequities and disparities in 2021 than did in 2020. An article about the research of RWJF and the Rand Corporation reported a loss in momentum of acknowledging the link between racism and health disparities. There appeared to be shift in attributing the problems to racism versus social determinants of health, in particular low income. Perhaps this is a function of more people feeling the impact of the pandemic on their own stability and less awareness or acknowledgement of other more entrenched barriers to daily living. The reassuring part of the research was that 68% of people still see the pandemic as a “launching pad for positive change.”

Research from the Boston School of Medicine raises fundamental questions about using race as an SDOH distinct from structural racism and its related impacts on other SDOH. The researchers emphasize the need to look at other factors and not include race. “If other factors (instead of race itself) determine the risk differences, then the prediction equations should incorporate those factors that cause the differences in predicted risk between the races, rather than race itself. If we do not change our prediction strategy, there is a risk of labeling (stereotyping) Black people as high risk purely based on the color of their skin,” explains corresponding author Vasan Ramachandran, MD, FACC”.

Kaiser Family Foundation and EPIC analyzed break-through COVID hospitalizations by age group and found the overwhelming percentage being 65+. This analysis does acknowledge that older adults are more likely to get vaccinated but indicates the percentage of breakthrough cases are a much higher percentage (69% versus 25%). I flag this research to further underscore the limitation of the large 65+cohort analysis and how it doesn’t break down frail elderly from simply crossing the threshold of 65.

Ascension St. John Foundation has committed $100 million to advance Tulsa health equity. “Through the Community Health Equity Catalyst Strategy (CHECS), the Ascension St. John Foundation is prepared to pump up to $10 million a year over the next 10 years into community agencies and organizations working across Tulsa to give each resident a fair and equitable opportunity to live a healthy lifestyle.” I know many health plans and health systems are investing in similar efforts, but some in such nominal amounts that will have no impact and others only towards their own members verses the broader community. I applaud the approach of the Foundation and CHECS!

Political determinants of health is a growing focus of needed change. This article reviews the discussion in a recent roundtable.  A quote from Daniel Dawes sums up the concept “Every social determinant of health that you can point to, there was some preceding legal, legislative, policy, or regulatory decision that resulted in the aforementioned social determinant,” How to make sustained changes in the current political environment is the elephant in the room. Many past newsletters highlight the policies that need to be changed or put in place to correct inequities, particularly in housing, policing, and transportation. Current politics around the Build Back Better Act is a daily reminder of the challenges.

I missed the November Aunt Bertha announcement that they were rebranding. I realized it when reading an article about the Michigan Health Information Network’s collaboration with Velatura Public Benefit Corporation and findhelp the new brand. The rebranding began in 2020 when they first launched ‘findhelp’ during COVID to help individuals find needed services. The tool is meant to help individuals connect to needed services near them focusing on social and community support. The platform and organizational tools are 100% free to nonprofit & community organizations in addition to individuals. Aunt Bertha/findhelp has been working on the social referral services effort on behalf of people in need since 2008. It is perhaps the longest standing national referral network and shows having over 8 million users. Their main competitors appear to be Now Pow and Unite US. Here is what they say differentiates their platform.

SIREN picks

Here is the link to the December SIREN newsletter. They include a yearend review and flag upcoming and past events. The research entries that caught my eye were:

Patient Perspectives: Value Food Insecurity (FI) Interventions and two liaison programs one for pediatrics and one for older adults.  The patient FI conclusions were “Screening paired with community food resource referrals and urgent-need food boxes are the most helpful interventions.” You’ll find the December research round up here.


I sat in on the CMS Innovation Center Health Equity Strategy Roundtable. It was an opportunity for invited thought leaders to respond to the CMS strategic white paper for the coming decade and to answer the following questions:

  1. What approaches or interventions should the CMS Innovation Center prioritize when building models to eliminate health inequities?
  2. CMS is currently exploring options for expanding collection of self-reported demographic and social needs data. What could the CMS Innovation Center do to support collection of self-reported data? What are successful approaches for such collection?
  3. What are the most significant obstacles for safety net providers who want to participate in a CMS Innovation Center or another value-based, accountable care model, and how do you recommend the CMS Innovation Center help these providers overcome these obstacles?

There was a lot of agreement on the need for CMS to simplify how organizations, particularly those with limited resources, can participate in innovation efforts. There was general agreement that there are too many measures and there need to be different measures.  There is a need to engage individuals, families, and communities and to expand the stakeholder engagement beyond health systems and community-based organizations. The event was characterized as the first of many discussions. Hopefully they will post a recording.

RISE Summit on Social Determinants, March 20-22, 2022, Nashville TN

AHA Community Health Improvement: Accelerating Health Equity Conference 2022– May 10-12, 2022 | Cleveland, OH 

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