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The Path Forward: The Digital Transformation in Social Determinants of Health

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The Path Forward: The Digital Transformation in Social Determinants of Health

  1. 1. COVID-19 Has Laid Bare a Harsh Truth People who are disenfranchised because of race, ethnicity, income, education, gender, environment— and more-- suffer inequity in health and life—including the length of life itself As FQHCs, we screen for, document, refer and, sometimes directly or indirectly, address SDoH . . . but we have not done enough to solve for them at scale 1
  2. 2. Social Determinants of Health Life Expectancy – age 40 Race and Ethnicity Adjusted 2 • Isolation/Loneliness • Food Insecurity • Transportation • HousingInstability • Environment • Safety(violence) Women Men Top 1% 88.9 87.3 Bottom 1% 78.8 72.7 60%-80% of health outcomes can be attributed to SDOH COVID-19 Deaths Per 100,000 people American Indian/ Native Alaskan 2.8x higher Blacks 2.1x higher Latinx 1.1x higher COVID-19 Deaths Life Expectancy -- Children Blacks Latinx Live in low-opportunity neighborhoods 7.6x whites 5.3x whites Results in 7-year reduction in life expectancy Pregnancy Mortality Rates (per 100,000 births) Whites Blacks American Indian 12.7 40.8 29.7 Why Social Determinants of Health Matter
  3. 3. What we are trying to do is move from “lower midstream” to “upper midstream” • Massive impact on the lives of the people we serve and costs to the healthcare system Let’s move from Lower Midstream to Upper Midstream Solving for Screening Social Needs 3
  4. 4. Serving the Underserved 4 Race U.S. Population Health Center Population Black 13% 22% Hispanic 18% 36% 91% of the people who walk through our doors live in or near poverty Source: HRSA.gov
  5. 5. Critical (adj): having a decisive or crucial importance in the success, failure, or existence of something Inflection point (n): a time of significant change in a situation; a turning point 5
  6. 6. Social inequities, social determinants of health, health related social needs, and health outcomes are all part of the continuum of health 6
  7. 7. 7
  8. 8. School to Prison Pipeline Source: 2020 American Civil Liberties Union 70% Of students involved in “in-school” arrests or referred to law enforcement are Black or Latino Black students are three and a half times more likely to be suspended than whites Black and Latino students are twice as likely to not graduate 3.5X 2X Black or Latino Black or Latino Of Incarcerated Population Of U.S. Population 61% 30% One out of three African American males will be incarcerated in his lifetime One out of six Latino males will be incarcerated in his lifetime 8
  9. 9. Black and Latinx populations have relatively lower levels of educational attainment and are underrepresented in higher paying occupations Employed people by occupation, race, and Hispanic or Latino ethnicity, 2018 annual Educational attainment of the labor force age 25 and older by race and ethnicity Source: U.S. Bureau of Labor Statistics, 2018 9
  10. 10. Redlined neighborhoods continue to have the highest share of Black residents 10Source: The Effects of the 1930s HOLC “Redlining” Maps by D. Aaronson, D. Hartley, B. Mazumder, 2016 National HOLC Grades and RaceNational HOLC Grades and % Black
  11. 11. 11
  12. 12. Intersectionality 12 • Typical Approach: Identity shaped by one (possibly two) lenses oRace, gender, class, sexual orientation . . . ? • Intersectionality: Identity shaped by myriad lenses oLooks at how race, gender, class sexual orientation etc. interact • Our identities are not easily defined, yet we tend to use one-lens labels. Understanding “lived experience” requires identifying people through many lenses.
  13. 13. What’s your street race? If you were walking down the street, what race do you think others that do not know you would automatically assume you were based on what you look like? Is race a thing or process? Why does how you conceptualize race matter for social determinants of health? 13
  14. 14. 2020 Census * Censo 2020 WHAT’S YOUR “STREET RACE”? FAMILY MEMBERS OF SAME ETHNICITY CAN AND SHOULD ANSWER THE RACE QUESTION DIFFERENTLY TO REFLECT THEIR UNIQUE RACIAL SOCIAL STATUS 14
  15. 15. Think back to when you were 16. What was yracial social geography (See Frankenberg 1993)? id thatInequities by Zip Code What are the limits of using zip code/census tract/neighborhood as proxy for SODH? What racialized-gendered-class complex inequities existed in your community? Now? 15
  16. 16. © 2015 IBM Corporation | 16Smarter Healthcare NOND-1162025-0001 The System Integrator • Creates a partnership across the medical neighborhood • Drives PCMH primary care redesign • Offers a utility for population health and financial management Away from Episode of Care to Management of Population with Data System Integrator Community Health Population Health Social Determents Health Patient Experience Public Health 16
  17. 17. © 2015 IBM Corporation | 17Smarter Healthcare NOND-1162025-0001 Driving factor 1: Unsustainable Cost (USA 2018) 17
  18. 18. © 2015 IBM Corporation | 18Smarter Healthcare NOND-1162025-0001 Driving factor 2: Data 18
  19. 19. © 2015 IBM Corporation | 19Smarter Healthcare NOND-1162025-0001 Driving factor 3: Communication 19
  20. 20. © 2015 IBM Corporation | 20Smarter Healthcare NOND-1162025-0001 Preventive medicine Medication refills Acute care Nursing Test results Source: Southcentral Foundation, Anchorage AK Behavioral health Case Manager Medical Assistants Chronic disease monitoring Practice transformation away from episode of care DoctorMaster Builder 20
  21. 21. © 2015 IBM Corporation | 21Smarter Healthcare NOND-1162025-0001 New model of care – putting the patient first Social Determents Acute mental health complaint Chronic disease compliance barriers Healthcare/Community Support Team Source: Southcentral Foundation, Anchorage AK Behavioral health Case Manager Clinician Medical Assistants Preventive medicine Medication refills Acute care Test results Chronic disease monitoring 21
  22. 22. © 2015 IBM Corporation | 22Smarter Healthcare NOND-1162025-0001 Data driven Every person has a plan Team based Managing a population down to the individual Future healthcare transformation 22
  23. 23. © 2015 IBM Corporation | 23Smarter Healthcare NOND-1162025-0001 A coordinated Health System Health IT Framework Global Information Framework Evaluation Framework Operations Specialists Public Health Prevention Community in action Public Health Prevention HEALTH WELLNESS Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators PCMH PCMH Community Care TeamHospitals 23
  24. 24. © 2015 IBM Corporation | 24Smarter Healthcare NOND-1162025-0001 Call & Check Providing support and care for all in the community 24
  25. 25. SDOH Value Chain Social determinant drivers Acute need Service access Service provision Temporary fix Repeat cycle Most effort, capital, and resourcing has been focused on sustaining this through state/federal support, direct reimbursement (maybe), and philanthropy What are the most persistent determinants? Why and how do these become complicated? How do people access services? Actively vs passively? What are the gaps in services? Is it reimbursement, access, or capacity? How long is the fix and how is it measured? 25
  26. 26. Opportunity for Innovation in SDOH Delivery Social determinant drivers Acute need Service access Service provision Temporary fix SDOH big data risk and predictive algorithms SDOH referrals Screening and identification solutions Digital access to services New service delivery Advanced payment with payors and providers 26
  27. 27. The Last Mile Reimbursement is accelerating as more states are leveraging Medicaid MCO contracts to facilitate SDOH  States are covering nonmedical services through community-based benefits  Integrating social supports into health plan management  Using value based payments on SDOH services  DSRIP in NYS  41 states are leveraging their Managed Care contracts and 1115 waivers to deploy SDOH services within Medicaid  This is also happening on the Medicare side as plans began to offer SDOH service coverage in 2019. 27
  28. 28. Social determinants are rooted in a community’s underlying social and economic conditions – issues such as racism, income inequality, climate change/environment etc. Not all social determinants lead to social risks for an individual. Social risks are the specific adverse social conditions that result from social determinants – issues such as food insecurity, isolation and housing instability. Not all social risk factors lead to “social needs” for an individual Social needs are adverse conditions and concrete needs that result from social risks. Goal #1: To provide concrete, actionable solutions that solve for the social needs that flow from social determinants • Surface innovators/disruptors creating evidenced-based products rooted in the efficient use of the latest technology, AI and data. Goal #2: To foster and build platforms for collaboration • Between FQHCs • Between FQHCs and hospital systems, community based organizations, payers • Between FQHCs and innovators/disruptors Goal #3: Advocacy • Policies related to social determinants • Payment systems The Path Forward:Webinar Terms 28
  29. 29. Webinars Structure and Timeline Two components to the series: Webinars • Subject Experts: Experts in the subject matter set the stage by providing relevant context, latest research), perspective on initiatives that have and have not worked previously. • Innovators and Disruptors: Companies that are creating new, evidenced-based products and services rooted in the use the latest technology, AI and data to solve for the social need in question. Roundtables • Led by subject experts. Designed to build collaboration between o FQHCs – best practices and lessons learned o FQHCs and hospital systems, community based organizations, payers – creating a decentralized whole-person care plan o FQHCs and innovators/disruptors – taking products that may 85% suited for our population and helping cross the finish line 29
  30. 30. The Path Forward Fall Schedule Topic Webinar Date Roundtable Date Screening to Solving for Social Needs August 20 Assessing Risk and Referral September 24 October 1 Isolation / Loneliness October 8 October 15 Food Insecurity October 22 October 29 Transportation November 12 November 19 Collaboration and Resources December 10 December 17 Registration for each roundtable open after corresponding live webinar Spring Series Topics dates TBD Housing Safety Environment Collaboration and Resources 30

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