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SDOH ForwardCollaborating to Overcome Barriers and Create Solutions


Welcome

Denise Koo, MD, MPHSenior Advisor for Health

Systems, Office of Public Health Scientific Services, Centers for

Disease Control and Prevention.

Alejandra GeppAssociate Director,

Institute for Hispanic Health, National Council of La Raza.

Paul B. Roth, MD, MSChancellor,

University of New Mexico Health Sciences Center, Dean, University of New

Mexico School of Medicine, Member, AAHC Board of

Directors.

Liz Tobin Tyler, JD, MAClinical Assistant Professor,

Brown University Alpert Medical School,

Brown University School of Public Health.


Paul B. Roth, MD, MS

Chancellor for Health Sciences

University of New Mexico Health Sciences Center

CEO, UNM Health System

Dean, UNM School of Medicine


Why SDOH?Health Reform and Value-Based Purchasing

•Greater efficiencies

•New models of care

•“Upstream” factors


Upstream Factors

•Genetics

•Environment

•Socio-Behavioral


The AAHC SDOH InitiativeA brief history . . .

2010 – UNM and UC Davis approach AAHC about a national movement to address the social determinants of health.2011 – UNM, UC Davis and AAHC co-sponsor Academic Health Centers and the Social Determinants of Disease: Measure our Success by our Population’s Health in Albuquerque, N.M.2012 – AAHC’s second meeting gathers together AHC leaders, state and local public officials.2014 – AAHC hosts third meeting in Washington, D.C., with 80 representatives from foundations, professional associations, academic health centers, public health agencies, the federal government and community organizations.


Summary of 2014 Meeting

Academic Health Centers and the Social Determinants of Health: Challenges & Barriers

• Income and health disparities• Allocation of social services spending vis-à-vis health care spending• Siloed responsibilities and resources• Workforce• Cultural and generational obstacles to interprofessional and

interdisciplinary collaborative practices• Erosion of public health’s role, status and resources



Academic Health Centers and the Social Determinants of Health: Challenges & Barriers

• Reimbursement methods

• Lack of community infrastructure

• Inadequacy of needed data

• Communication, messaging and advocacy

• Rigidity of accreditation and licensure

• Cumulative impact on academic health centers



Academic Health Centers and the Social Determinants of Health: Responses & Solutions

• Achieve consensus on priority responses to barriers

• Establish effective systems to coordinate and share data

• Align public payment methods with efforts to address social determinants of health and disease

• Develop consensus measures, methods and approaches to harmonize community health needs assessments and facilitate consistent decision-making among all entities




• Create an appropriately sized and trained workforce to address the social determinants of health

• Coordinate investments of public and private stakeholders in the local social infrastructure




Create a formal academic health center collaboration to:

• Develop best practices for community partnerships

• Translate these practices into a strong, shared message

• Work closely with major public/private stakeholders

• Learn from newer AHCs that incorporate social determinants




Create a formal academic health center collaboration to:

• Develop strategies to overcome cultural biases

• Lead the way in developing data sources, research tools and metrics

• Develop cohesive messages for use locally and nationally to increase awareness

SOCIAL DETERMINANTS OF LATINO HEALTH

Alejandra Gepp, Associate Director

Institute for Hispanic Health, NCLR

[email protected]

(202) 776-1818

Association of Academic Health Centers

March 18, 2015

Overview

Latinos in the United States

Latinos’ Health Barriers

Social Determinants of Latino Health

Environmental Factors

What Causes Health Inequities?

–World Health Organization,

Commission on the Social Determinants of Health

NCLR’s Approach

NCLR’s Approach

Promoting Wellness for Populations with Health Disparities and Underserved Communities

Improving Access to Care for Immigrant and Mixed-Status Families

Improving Health Care Access and Quality for Limited-English-Proficient Populations

Promoting Health and Wellness

Access to Health Care for Immigrant Families

Conduct outreach to and enroll eligible family members

Preserve child-only plans

Streamline verification

Promote access to alternative paths to care

Remove exclusion and five-year bar

Access to Health Care for Immigrant Families

Undocumented immigrants excluded from exchanges

Layers of citizenship or legal status verification imposed

Impact on mixed-status families

Five-year bar to Medicaid not lifted for legal immigrants

Improving Health Care Access and Quality for Limited-English-Proficient Populations

§1557 of the Affordable Care Act prohibits discrimination based on race, national origin (including language), gender, age, or disability.

This applies to activities and programs receiving federal funds or administered by an agency or entity created by the legislation.

It should apply to exchanges and

qualified health plans.

Policy and Program Recommendations

Denise Koo, MD, MPH

[email protected]

SDOH ForwardMarch 18, 2015

Academic Health Centers andthe Social Determinants of Health

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

mailto:[email protected]

Selected Themes and Recommendations in the AAHC SDOH Report

Need for more effective messaging regarding impact

of SDOH on health, both inside and, especially,

outside the healthcare system

Need for more evidence as to which interventions

make a measurable difference regarding individual,

community, and population health…

Detrimental consequences of siloed responsibilities

and resources within/among stakeholders at local,

county, state, and federal level

Recommendation: Harmonization of community

health needs assessments

Recommendation: Improved social infrastructure

AHA: Leadership Toolkit for Redefining the “H”

“Maintaining the status quo is not an option moving forward”

“H” …Much more than “Hospital.” People should see it and

think of “Health.” …Our focus should be on determinants of

health, not just health care or hospital care.”

“Hospitals must reconsider, how they alone, or through diverse

partnerships with aligned goals and resources can best fulfill

their mission of improved health for patients and

communities.”

“First and foremost, leaders must look for opportunities to

improve the quality of care provided, identify strategies to

provide more efficient, high-quality care and work with

communities to go “upstream” to address determinants of

health.http://www.aha.org/research/cor/redefiningH/index.shtml?utm_source=newsletter&utm_medium=email&utm_c

ampaign=NewsNow

http://www.aha.org/research/cor/redefiningH/index.shtml?utm_source=newsletter&utm_medium=email&utm_campaign=NewsNow

Required to conduct Community Health Needs

Assessment every 3 years and adopt an

implementation strategy (and update it annually)

Permits addressing of health needs arising from

social conditions

Joint planning activities with other hospitals and

public health encouraged

Input from governmental public health required (but

hospitals can select which jurisdictional level)

Definition of community: the community that needs

the care of the hospital

Input from persons representing the community

required

ACA IRS Final Rule for Tax-exempt Hospitals

Examples of Health Centers Addressing SDOH

Charlestown (area of Boston): opioid overdoses were reduced

by 50% (2004-2012) and drug-related deaths by 78% (2003-2008)

Partnership between Massachusetts General Hospital,

Charlestown Substance Abuse coalition, Charlestown Drug Court,

Boston Public Health Commission, and a social marketing firm.

How: together they run an anti-prescription drug overdose social

marketing campaign, make referrals to treatment facilities, offer

treatment as an alternative to incarceration, run substance abuse

curriculums for children, and train local residents in Narcan use.

In its first year as an ACO, Montefiore Medical Center reduced

the cost of care for its 23,000 Medicare patients by 7% and

earned $14 million in shared savings payments from CMS

How: by partnering with community organizations to provide

wraparound services including housing, legal, financial,

employment, and transportation assistance.

Role of Health Centers as Anchor Institution for Community-Univ Pittsburgh

By partnering with local housing authority, a local primary care

practice and Community Health Services to provide stable

housing, case management and primary healthcare services,

Univ Pitt Med Center reduced overall per-member-per-month

claims costs by 23%

Big strides were made in education in Pittsburgh thanks to

investment in the Pittsburgh Promise scholarship program

through a partnership among the University of Pittsburgh

Medical Center, Pittsburgh Public Schools, the Pittsburgh

Foundation, and other funders. The program provides

scholarships for Pittsburgh Public Schools alums to attend

Pennsylvania colleges and helped increase the local high

school graduation rate in public schools from 63% to 72%. It

also led to greater number of graduates enrolling in post-

secondary education, a bump of 58% to 68%, and the city’s first

population growth in 50 years.

SELECTING ACTIONS TO IMPLEMENT

Queriable Database of High-value Potential Interventions:

CDC Community Health Improvement Navigator

Selected examples of hospitals successfully

addressing SDOH

Infographic/storyline underscoring importance of

Partnership

Balanced portfolio of actions

Highlighted tools supporting key concepts

Database of Interventions

www.cdc.gov/CHInav (full site live in late April 2015)

http://www.cdc.gov/CHInav


Liz Tobin Tyler, JD, MAAssistant Professor, Warren Alpert Medical School and School of Public Health

Brown University

Consultant, National Center for Medical-Legal Partnership


Objectives

1. Explain Medical-Legal Partnership (MLP) Approach

Building a healthcare team able to identify, treat and prevent health-harming legal needs for patients, clinics and populations.

2. Describe interprofessional MLP Education

3. Explore opportunities for MLP & AAHC collaboration


Common Legal Problem Social Determinant of Health

Families wrongfully denied food supports or housing subsidies

Lack of basic resources

Children living in housing with mold or rodents, in violation of housing laws

Physical environment

Seniors wrongfully denied long-term care coverage

Lack of access to insurance

Making the connection:Legal problems are health problems.


HEALTHCARE

treats illnesses caused or

exacerbated by SDOH.

LEGAL AID

ensures access to benefits &

services, enforces laws that keep people healthy.

PUBLIC HEALTH

tracks diseases on population level, addresses laws & education aimed

at prevention.

Three Sectors AddressSocial Determinants of Health in Silos


MLPs help patients with I-HELP® issues


• Identify the social, economic and environmental determinants of health

• Understand the role of law and policy in shaping & addressing those determinants

• Develop skills in systems-thinking and policy advocacy strategies

• Practice hands-on interprofessional team-based problem-solving strategies for patients and populations

MLP Education Teaches Students to…


Undergraduate

• Preclinical curriculum (often joint with law, social work, nursing)

• Clinical rotations/clerkships at MLP sites

Graduate

• Residency program curriculum

• Noon conferences

• Grand Rounds

• Practice in screening for SDH/unmet legal needs

MLP in Medical Education


Poverty, Health and Law textbook (2011): the intersection of health and unmet legal needs

Accessible to medical, legal, nursing, social work & public health students

Interprofessional case studies

“Patients to Policy” examples

Medical-Legal Partnership Curriculum


Residents who received MLP education were more:

• comfortable discussing social determinants

• knowledgeable about resources

• likely to document issues such as public benefits, housing and education

• likely to refer patients to legal services

Sources: Klein, MD., Training in Social Determinants of Health in Primary Care: Does It Change Resident Behavior? 2011; Acad Ped 11(5): 387-393; Cohen, E., Medical-Legal Partnership: Collaborating with Lawyers to Identify and Address Health Disparities. 2010; J Gen Int Med 25(Suppl 2):136–9.

Changes in Practice after MLP Education


Challenges

• Disconnect between clinical and community (silos)

• Legal and systems barriers to accessing community resources (more than referrals needed)

• Lack of funding/infrastructure for integrated approaches to SDOH


Opportunities

Integrate MLPs into Academic Health Centers to:

• address SDOH through fully integrated interprofessional team

• connect clinical to community & population health

• expand interprofessional education/training for health care professionals

• Systems• Advocacy• Policy


QUESTIONS & DISCUSSION

Denise Koo, MD, MPHSenior Advisor for Health

Systems, Office of Public Health Scientific Services, Centers for

Disease Control and Prevention.

Alejandra GeppAssociate Director,

Institute for Hispanic Health, National Council of La Raza.

Paul B. Roth, MD, MSChancellor,

University of New Mexico Health Sciences Center, Dean, University of New

Mexico School of Medicine, Member, AAHC Board of

Directors.

Liz Tobin Tyler, JD, MAClinical Assistant Professor,

Brown University Alpert Medical School,

Brown University School of Public Health.

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