Archive for the ‘Social Determinants of health’ Category

Infographic: Addressing Social Determinants of Health Can Improve Community Health and Reduce Costs

December 6th, 2019 by Melanie Matthews

Studies estimate that social determinants of health influence 50 percent of health outcomes, yet many communities are reporting unmet social needs like food insecurity or concerns about community safety, according to a new infographic by the National Institute for Health Care Management Foundation.

The infographic offers an overview of the social determinants of health, their implications for health outcomes and costs, and solutions to address unmet needs.

2019 Healthcare Benchmarks: Social Determinants of HealthOne-third of Americans are grappling with stress tied to meeting their basic human needs such as stable housing, adequate food, and reliable transportation, according to the results of a new national survey from Kaiser Permanente. The survey, Social Needs in America, also found that Americans overwhelmingly want healthcare providers to be involved in identifying and addressing these non-medical social needs.

2019 Healthcare Benchmarks: Social Determinants of Health is the second comprehensive analysis by the Healthcare Intelligence Network of programs aimed at addressing social determinants of health (SDOH), including populations prioritized for SDOH screening, preferred screening tools, interventions, results and ROI.

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Infographic: Insights from McKinsey’s Consumer Social Determinants of Health Survey

October 7th, 2019 by Melanie Matthews

Food security was the most common unmet social need, according to a survey by McKinsey & Company on consumers’ views of social determinants of health. Survey highlights are featured in an infographic by McKinsey & Company.

The infographic sheds light on how social determinants of health affect healthcare utilization rates and consumers’ interest in social program offerings.

2019 Healthcare Benchmarks: Social Determinants of HealthOne-third of Americans are grappling with stress tied to meeting their basic human needs such as stable housing, adequate food, and reliable transportation, according to the results of a new national survey from Kaiser Permanente. The survey, Social Needs in America, also found that Americans overwhelmingly want healthcare providers to be involved in identifying and addressing these non-medical social needs.

2019 Healthcare Benchmarks: Social Determinants of Health is the second comprehensive analysis by the Healthcare Intelligence Network of programs aimed at addressing social determinants of health (SDOH), including populations prioritized for SDOH screening, preferred screening tools, interventions, results and ROI.

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Infographic: Top 10 Promising Population Health Approaches

September 30th, 2019 by Melanie Matthews

Public health officials are key in leading strategies and crafting policies that foster clinical innovation, leverage data analytics and public health informatics and address social determinants of health to advance health equity and improve population health, according to a new infographic by the Association of State and Territorial Health Officials.

The infographic identifies 10 approaches that state and territorial health officials may explore with their partners in the community, healthcare sector and other governmental agencies to achieve optimal health for all.

2018 Healthcare Benchmarks: Population Health ManagementAs the healthcare industry’s pace from volume-based to value-based healthcare payment models accelerates so does the demand for more effective management of population health. With the growth of these payment models, healthcare organizations are taking on more risk in terms of shared savings and shared risk arrangements and are investing heavily in programs to support population health. These programs are expanding in both scope of services and health conditions and disease states managed. With the help of advanced technologies in healthcare, this growth will only continue.

2018 Healthcare Benchmarks: Population Health Management is the fourth comprehensive analysis of population health management by the Healthcare Intelligence Network, capturing key metrics such as populations, health conditions and health risk levels targeted by population health management programs; risk stratification criteria; prevalence of value-based payment models supporting population health management programs; population health management processes, tools, workflows and forms; and program outcomes and ROI from responding healthcare organizations. Click here for more information.

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Infographic: Community Health Navigators Address Social Determinants of Health to Impact High Hospital Utilization

July 29th, 2019 by Melanie Matthews

AmeriHealth Caritas leverages its community care management teams led by a medical director and consisting of community health navigators, community care managers, and a program manager to engage high- and emerging-risk members to increase their access to care and improve their overall healthcare experience through care management services delivered in member homes, with an emphasis in screening for and addressing social determinants of health (SDOH), according to a new infographic by AmeriHealth Caritas.

The infographic examines AmeriHealth Caritas’ success in identifying and addressing specific SDOH vulnerabilities at both the population and member levels.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community ServicesLeveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore’s approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients” well-being, and then connecting high-need individuals to community-based services. Click here for more information.

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Infographic: Prescribing Healthy Food in Medicare/Medicaid

July 3rd, 2019 by Melanie Matthews

Health insurance coverage for healthy food could improve health, reduce healthcare costs and be highly cost-effective after five years, according to a new infographic by Tufts University.

The infographic examines the health and economic effects of healthy food prescriptions in Medicare and Medicaid.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community ServicesLeveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore’s approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients” well-being, and then connecting high-need individuals to community-based services. Click here for more information.

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Infographic: Should Ride-sharing Be Added to a Healthcare Benefit Plan?

April 8th, 2019 by Melanie Matthews

As the public discourse continues to focus on the high cost of healthcare, an increasing number of payers and healthcare organizations are turning to ride-sharing services such as Uber or Lyft for non-emergency medical transportation, according to a new infographic by Healthcare Town Hall based on an article by Milliman.

The infographic outlines a number of considerations for healthcare organizations thinking of adding ride-sharing as part of a benefit plan.

Innovative Community Health Partnerships: Clinical Alliances to Reduce Health Disparities in Underserved PopulationsAs one of the poorest urban congressional districts in the country, the Bronx, a New York City borough, was also rated as the last county (#62) in New York for health outcomes and health factors by the Robert Wood Johnson Foundation. In reaction, the Bronx Health REACH initiative formed the “#Not62,” campaign to transform the health of the community.

Innovative Community Health Partnerships: Clinical Alliances to Reduce Health Disparities in Underserved Populations highlights the models of change and key initiatives developed through Bronx Health REACH’s community health transformation project.

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Infographic: Addressing Social Health Determinant Barriers to Better Health

February 20th, 2019 by Melanie Matthews

Addressing social determinants of health (SDOH) has become a top priority for public and private healthcare institutions, according to a new infographic by BCBS ProgressHealth.

The infographic examines how Blue Cross and Blue Shield plans are addressing SDOH.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community ServicesLeveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore’s approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients” well-being, and then connecting high-need individuals to community-based services. Click here for more information.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Infographic: Blueprint for Complex Care

January 11th, 2019 by Melanie Matthews

The United States spends more on healthcare than any other industrialized nation, and much of that spending is concentrated on a small percentage of individuals with complex medical, behavioral, and social needs, according to a new infographic by the Center for Health Care Strategies.

The infographic highlights recommendations for advancing the field, based on input from stakeholders across the country.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team’s bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

The Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed’s four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

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Infographic: How Housing Affordability Matters in Healthcare

January 9th, 2019 by Melanie Matthews

Housing affordability is a social determinant of health. A lack of affordable housing contributes to housing instability and homelessness, both of which are strong predictors of higher healthcare costs and poor health outcomes, according to a new infographic by the State Health Access Data Assistance Center.

The infographic breaks down the issue of unaffordable rents and explores how state Medicaid policy can alleviate the burden of unaffordable rents.

Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge HousingChronic homelessness and chronic illness often go hand in hand; individuals struggling with housing insecurity frequently suffer a range of health problems that require hospitalization. Unfortunately, lacking stable housing where they can recuperate renders these newly discharged patients more likely to return to the hospital.

Recognizing that housing is healthcare, many healthcare organizations, particularly hospitals, now seek ways to address this social determinant of health (SDOH) by identifying housing barriers in their communities and developing initiatives to improve housing availability.

Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing spotlights a California partnership that provides medical ‘bridge’ housing to homeless patients following hospitalization. This recuperative care initiative reduced avoidable hospital readmissions and ER visits and significantly lowered costs for the collaborating organizations.

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10 Critical Care Coordination Model Elements for Medicaid Managed Care Members

May 17th, 2018 by Melanie Matthews

There are 10 critical elements of the care coordination model for Independent Health Care Plan (iCare) Medicaid managed care members, according to Lisa Holden, vice president of accountable care, iCare.

The first element and touchpoint for Medicaid managed care members is their care coordinator. “Every single one of our incoming SSI Medicaid members is assigned to a care coordinator,” Holden told participants in the May 2018 webinar, Medicaid Member Engagement: A Telephonic Care Coordination Relationship-Building Strategy, now available for replay. “That person is responsible for everything to do with that member’s coordination of care.”

Care coordinators are assigned to every Medicaid member and are responsible for engaging and coordinating member’s care needs.

“We want our care coordinators to make an initial phone call as early as a couple of days after the member is enrolled in our plan,” she said. “If the member is interested in having a conversation, we offer to conduct a health risk assessment. But if the timing isn’t right, then we offer to schedule another appointment. There’s no pressure except that we want them to feel engaged by us.”

Once completed, the health risk assessment forms the basis of an interdisciplinary individualized care plan created by the care coordinator with the member.

The care coordinator, who is a social worker by background, has access to a nurse, who is available for medically complex members, said Holden.

iCare also relies on health coaches. Health coaches are now teaming up with a care coordinator as much as, if not more than, the nurses are historically, Holden said.

“Our health coaches are literally assigned to work in the community to become very familiar with the resources that are available,” she added. “They are becoming steeped in the communities in which they serve. Each one is assigned to a neighborhood, and we’ve asked them, ‘Get to know the police. Get to know the fire. Get to know the food organizations and food pantries. Get to know the housing specialists in your area.'”

The health coaches also help the care coordinators locate difficult-to-contact members by being in the community as a boots on the ground force. They’re also focused on assessing and addressing social determinants of health.

“We really believe that health coaches are going to be the key to our success in this year and in years to come,” Holden explained.

In addition to the care coordinators, health coaches and nurses, the care coordination team includes two specialized positions…a trauma-informed intervention specialist and a mental health and substance abuse intervention specialist. “We brought those two specialties into this program for our Medicaid members because we know that there’s a high instance of behavioral health conditions, which usually has another diagnosis of alcohol and drug use, not always, but quite often. We wanted to have the team ready to engage the member,” said Holden.

Once the member is engaged, iCare’s care coordination team begins to identify unmet needs, she explained. “We want to know, ‘Is their life going well? Do they have appropriate medical care? Are they in a relationship with a primary care provider that they feel is co-respectful? Are they getting their answers to their questions?'”

To begin talking about medical needs, the care coordination team has to establish trust, said Holden. “We have to talk with the member in an honest way that reflects our respect for them and also engages them in order for them to tell us how they really feel.”

iCare uses the Patient Activation Measure tool to help identify where the member is in a spectrum of four different levels of activation. iCare then tailors its member engagement approach to build a trusting relationship and provide member education by recognizing where they are in their activation level.

Following up on preventive measures are key for the iCare care coordination model. Care coordinators reach out to members for care plan updates. The care plan has to be alive and very member-centric, said Holden. The health risk assessment is repeated each year and the care plan is updated based on those results.

iCare is also focusing on social determinants of health with the recognition that they impact a members’ health more than clinical care. Clinical care attributes to only about 20 percent of somebody’s health outcomes; the rest of that 80 percent is made up of by health behaviors, social and economic factors, and physical environment. “If we don’t get underneath those issues, we can ask for things to improve, but we’re going to see minimal success,” Holden added.

During the webinar, Holden also shared: how the care coordinators helps Medicaid members overcome barriers to care; seven rising risk/acuity identification tools; readmission prevention initiatives for high-risk patients; three programs aimed at reducing high emergency department utilization; and details on a Follow-to-Home program for members who are homeless. Holden also shared: details on language to use…and not to use…when engaging members; advice on the best time to connect with members by phone, such as time of day, specific days of the months; the role of the specialist interventionist compared to the care coordinator; and the background of iCare’s care coordinators and health coaches.

Click here to view the webinar today or order a DVD or CD of the conference proceedings.