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Deepening Disparities Continue for Vulnerable Populations

A preview of issues on the SDoH Radar for 2021.

We are less than two weeks into 2021, but the priority for healthcare organizations continues to be … wait for it … the social determinants of health (SDoH) and mental health (SDoMH). The industry’s hot-ticket item, pre-pandemic, has only grown in importance due to deepening disparities for already vulnerable and marginalized populations, as well as growing numbers of people in need of psychosocial, economic, and other resource support.

What industry response can we expect to see in 2021? Here are a few things to put on your SDoH radar!

  • Programs that leverage social informatics. These efforts strive to achieve the holy grail of interoperability and close the care gap for patients across health organizations, from input to throughput, resource linkage, and follow-up. Stakeholder eyes will be on the outcomes of the RWJBarnabas Health Beyond Hospital Program, the cross-sector collaboration geared to screen every patient for SDoH conditions, connect them to community services, and provide ongoing support.
  • Programs to address the rising population impacted by homelessness and housing insufficiency: one model continues to be The Homeless Outreach Medical Services (HOMES) program, a collaboration between Parkland Hospital in Dallas and the Children’s Health Fund that provides medical, dental, and behavioral health services to children and adults who are homeless.
  • Highmark Blue Cross Blue Shield of Delaware has formalized a collaboration with (formally Aunt Bertha) that ensures beneficiaries at risk of the SDoH receive direct access to identified resources.
  • With unemployment back on the rise, programs as CareSource’s JobConnect platform will expand. This initiative links members with employment by offering education and skill-building programs.
  • Food is medicine! Model programs and coalitions will rapidly expand to mitigate food insufficiency. Rising numbers of food pharmacies in hospitals will continue to emerge based on the Geisinger model. Payors will step up, as the Centene subsidiaries are partnering efforts with community-based organizations that provide access to food and other essential supplies across states.
  • Efforts to close the racial and cultural gap for maternal mortality are growing across rural and urban communities. Several winner of AHRQ grants focused on rural postpartum mental health:
    • $50,000 in cross-sectional innovation prizes went to St. Peter’s Health in Helena, Mont. for its maternal mental health program, which identifies at-risk individuals and connects women to resources and appropriate care early in pregnancy
    • Pack Health in Birmingham, Ala. received a grant for a digital health coaching program to address postpartum depression
    • $25,000 in prizes went the to Massachusetts Child Psychiatry Access Program for Moms; Flathead County, Montana’s Postpartum Resource Group; and the Art Heals: Wellness Workshops for Postpartum Women program from Oregon
  • Mergers, acquisitions, and collaborations that address what I have labeled the wholistic health triad for vulnerable populations will grow! These efforts provide comprehensive wraparound care for physical and mental health, plus psychosocial circumstances. On the Centene front, their planned acquisition of Magellan Health is aligned with this goal: to support their very marginalized beneficiaries with complex, chronic conditions through integration of physical and mental healthcare.

We recently asked our Monitor Mondays listeners what SDoH programming their organizations were prioritizing for this New Year, with the results here. More highlights are on the SDoH horizon, and I’ll continue to report on them over this year. Stay tuned to my weekly State of the Social Determinants report on Monitor Mondays, and upcoming articles in RACmonitor.

Programming Note: Listen to Ellen Fink-Samnick’s live reporting on the social determinants of health every Monday on Monitor Mondays, 10 a.m. Eastern.

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Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning healthcare industry expert. She is the esteemed author of books, articles, white papers, and knowledge products. A subject matter expert on the Social Determinants of Health, her latest books, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and Social Determinants of Health: Case Management’s Next Frontier (with foreword by Dr. Ronald Hirsch), are published through HCPro. She is a panelist on Monitor Mondays, frequent contributor to Talk Ten Tuesdays, and member of the RACmonitor Editorial Board.

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