Track 1: The Digital Transformation in Social Determinants of Health First Session: Thursday, August 20, 2020, 2-3pm ET

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. 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. 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. 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. 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. Social inequities,
social determinants
of health, health
related social
needs, and health
outcomes are all
part of the
continuum of health
6

7. 7

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. 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. 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

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. 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. 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. 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. © 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. © 2015 IBM Corporation | 17Smarter Healthcare
NOND-1162025-0001
Driving factor 1: Unsustainable Cost (USA 2018)
17

18. © 2015 IBM Corporation | 18Smarter Healthcare
NOND-1162025-0001
Driving factor 2:
Data
18

19. © 2015 IBM Corporation | 19Smarter Healthcare
NOND-1162025-0001
Driving factor 3:
Communication
19

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. © 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. © 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. © 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. © 2015 IBM Corporation | 24Smarter Healthcare
NOND-1162025-0001
Call & Check Providing support and care for
all in the community
24

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. 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. 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. 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. 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
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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