rwjf-tag: Addressing social determinants of health

van Beek, E., Eckel, D., & Taylor, A. (2018, March). Investing in social services as a core strategy for healthcare organizations: Developing the business case. Washington, DC: KPMG Government Institute and The Commonwealth Fund.

This report explores the current landscape of investments targeting the social determinants of health (SDH) as well as approaches to accelerate the uptake of SDH investments into healthcare business operations through key informant interviews with healthcare payer and provider executives, an extensive literature review, and the convening of an Advisory Council and a Social Services… Read more »

The Commonwealth Fund. No date. HNHC Payments for Social Services Calculator (BETA) [Web site].

This calculator is designed to assist community-based organizations and their medical partners in creating mutually advantageous financial arrangements for funding the delivery of social services to high-need, high-cost (HNHC) populations. These populations, which account for a disproportionately large share of health care expenditures, often have clinically complex conditions, cognitive or physical limitations, and/or behavioral health… Read more »

Soper, M. (2017, January). Providing value-added services for Medicare-Medicaid enrollees: Considerations for integrated health plans. Hamilton, NJ: Center for Health Care Strategies, Inc.

This brief explores how health plans participating in PRIDE (Promoting Integrated Care for Dual Eligibles), a project made possible by The Commonwealth Fund, are addressing members’ service needs beyond the scope of traditionally covered Medicare and Medicaid services to improve health outcomes and address social determinants of health. The brief also discusses several policy considerations… Read more »

Solomon, L.S., & Kanter, M.H. (2018). Health care steps up to social determinants of health: Current context. Permanente Journal, 2018(22), 18-139.

This article provides an overview of what the role for the United States’ health care system is in addressing the social determinants of health, how to create the right policy context for innovation, and how healthcare can partner more effectively with providers of social services to meet patients’ most pressing needs given the fragmented, typically… Read more »

Romero, D., Echeverria, S.E., Du, M., Roberts, L., & Pozen, A. (2018). Development of a wellness trust to imprve population health: Case-study of a United States urban center. Preventive Medicine Reports, 2018(10), 292-298.

This study aimed to understand the necessary tenets for a wellness trust in Brooklyn, New York and examined community interest and political will; administrative, financing, and leadership structures; and metrics and data sources to monitor and assess impact. Wellness trusts, modeled after financial trusts support primary health prevention in community settings, provide an innovative opportunity… Read more »

Robert Wood Johnson Foundation. (2019, February). Medicaid’s role in addressing social determinants of health (Briefing series: Key Medicaid issues for new state policymakers). Princeton, NJ: Author.

This brief discusses three issues for state policymakers to consider as they implement strategies to address social determinants of health and aim to integrate such efforts into delivery of health care. Namely, state officials should consider: 1) covering selected non-medical services; 2) integrating social supports into health plan care management; and 3) using value-based payments… Read more »

Regenstein, B.M., Trott, J., Williamson, A., & Theiss, J. (2018). Addressing social determinants of health through medical-legal partnerships. Health Affairs, 37(3), 378-385.

This article draws upon national survey data and field research to identify three models of the medical-legal partnership that health care organizations have adopted and the core elements of infrastructure that they share. The medical-legal partnership is a collaborative intervention that embeds civil legal aid professionals in health care settings to address seemingly intractable social… Read more »

Powers, M. (2018). The community’s emerging role in value-based health and social services. Generations: Journal of the American Society on Aging, 2018(Spring), 4-9.

This article examines how healthcare organizations are exploring closer partnerships with community-based organizations (CBOs), especially for high-need, high-cost populations. Social determinants of health are known to impact health outcomes, and there is growing recognition that non-medical services are as important as those received in a provider’s office. The article describes payment methods for these populations,… Read more »

Oostra, R., & Zuckerman, D. (2018, May). Embracing an anchor mission: ProMedica’s all-in strategy. Toledo, OH and Washington, DC: ProMedica and The Democracy Collaborative.

This report describes ProMedica’s (a mission-based, not-for-profit healthcare organization serv- ing northwest Ohio and southeast Michigan) shift to an Anchor Mission. This mission is embedded in an overall strategy related to addressing the social determinants of health as a whole. With that in mind, ProMedica has made a commitment to apply its economic power and… Read more »

Moving Healthcare Upstream. (2018). Policy Leadership for Health Care: Transformation Formalizing Our Commitment to Communities. Wilmington, DE; Author.

This paper identifies specific institutional policies and civic engagement strategies that can be used by hospitals and health systems to codify, sustain, and scale practices that address social determinants of health (SDH) in local communities. This paper synthesizes these exemplars using a framework of key principles and associated activities and policies required for system transformation… Read more »

McGinnis, T., Crumley, D., & Chang, D. (2018, May). Implementing social determinants of health interventions in Medicaid managed care: How to leverage existing authorities and shift to value-based purchasing. Washington, DC: Academy Health.

This brief illustrates how states can use existing Medicaid authority to finance innovative upstream prevention and population health initiatives. In 2017, Nemours Children’s Health System contracted with the Center for Health Care Strategies (CHCS) to work with the PacificSource Columbia Gorge Coordinated Care Organization (CCO), a regional Medicaid payer operating as the sole managed care… Read more »

Machledt, D. (2017, November 29). Addressing the social determinants of health through Medicaid managed care. Washington, DC: The Commonwealth Fund.

This brief explores the impact of several provisions of the Centers for Medicare and Medicaid 2016 updated Medicaid managed care rule’s influence states’ ability to address social determinants of health through managed care. Several provisions in the new Medicaid managed care rule signal CMS’s intent to increase access to high?value nonmedical interventions. For instance, the… Read more »

Hostetter, M., & Klein, S. (2017, June 21). Creating pathways and partnerships to address patients’ social needs. Washington, DC: The Commonwealth Fund.

This article examines how new technologies and payment models can support efforts by health care providers and plans to assess patients’ nonmedical risks and work with nonprofit agencies, social services providers, and other community partners to help address them. The article provides examples of how hospitals/health systems address nonmedical needs, how to build clinical-non-clinical partnerships,… Read more »

Georgia Health Policy Center & Robert Wood Johnson Foundation. (2016, October). Financing population health: abridge version. Atlanta, GA: Andrew Young School of Policy Studies, Georgia State University.

This report describes innovations in financing that can be used to improve population health. Eight innovations are described, with examples of each provided: 1) capture and reinvest; 2) blending and braiding; 3) community development financial institutions; 4) hospital community benefits; 5) low-income housing tax credits; 6) new market tax credits; 7) social impact bonds; and… Read more »

Freda, B., Kozick, D., & Spencer, A. (2018, January). Partnerships for health: Lessons for birdging community-based organizations and health care organizations. Boston, MA and Hamilton, NJ: Blue Cross Blue Shield of Massachusetts & Center for Health Care Strategies, Inc.

This brief draws on insights gleaned from the Robert Wood Johnson Foundation’s Partnership for Healthy Outcomes project and the Blue Cross Blue Shield of Massachusetts Foundation June 2017 conference which convened several health care organizations (HCO) – community-based organization (CBO) partnerships to share promising partnership models. It outlines characteristics of successful HCO-CBO partnerships and provides… Read more »

Daniel-Robinson, L, & Moore, J.E. (2019, January). Innovation and opportunities to address social determinants of health in Medicaid managed care. Washington, DC: Institute for Medicaid Innovation.

This article identifies opportunities within the Medicaid program to identify and address the unmet social needs and risk factors that have a significant impact on health outcomes and costs. With access to enrollee health data, Medicaid managed care organizations (MMCOs), with the support of state Medicaid agencies and community-based organizations (CBOs), are well positioned to… Read more »

Crumley, D., Lloyd, J., Pucciarello, M., & Stapelfield, B. (2018). Addressing social determinants of health via Medicaid managed care contracts and section 1115 demonstrations. Hamilton, NJ and Washington, DC: Center for Health Care Strategies, Inc. & the Association for Community Affiliated Plans.

This report examines Medicaid managed care contracts or requests for proposals (RFPs) in 40 states, in addition to 25 approved section 1115 demonstrations. Incentives and requirements related to the social determinants of health (SDH) are compiled, common themes in the states’ approaches are identified, and recommendations are developed for federal policymakers, including the Centers for… Read more »

Bush, M. (2018). Addressing the root cause: Rising health care costs and social determinants of health. North Carolina Medicine Journal, 79(1), 26-29.

This article describes how North Carolina plans to use its Medicaid expansion to address social determinants of health. The expanded Medicaid is designed to convert North Carolina’s fee-for-service program into a managed care health delivery system, with managed care organizations (MCOs) controlling costs by managing overall population health for beneficiaries through lump sum payments that… Read more »

Berkowitz, S.A., Brown, P., Brotman, D.J., Deutschendorf, A., Dunbarb, L., Everetta, A., … On behalf of the J-CHIP Program. (2016). Healthcare case study: Johns Hopkins Community Health Partnership: A model for transformation. Healthcare, 2016(4), 264-270.

This article describes the Johns Hopkins Community Health Partnership (J-CHiP), a partnership between Johns Hopkins Medicine (JHM) and two grassroots community-based organizations (CBO). J-CHiP is a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. J-CHiP was formed as a regional approach to transformation… Read more »

Bachrach, D., Guyer, J., Meier, S., Meerschaert, J., & Brandel, S. (2018, January 31). Enabling sustainable investment in social interventions: A review of Medicaid managed care rate-setting tools. Washington, DC: The Commonwealth Fund.

This article explores practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues using a literature review, interviews with stakeholders, and analysis of federal regulations. The following strategies were identified: 1) classify certain social services as covered benefits under the state’s Medicaid plan; 2) explore… Read more »

Ash, A., Mick, E., Ellis, R., Kiefe, C., Allison, J., & Clark, M. (2017). Social determinants of health in managed care payment formulas. JAMA Internal Medicine, 177(10), 1424-1430.

This article seeks to answer the question, can social determinants of health (SDH) be included in Medicaid payment formulas so as to pay more equitably for the care of socially vulnerable individuals? Managed care payment formulas commonly allocate more money for medically complex populations, but ignore most SDH. Outcomes examined overall were model explanatory power,… Read more »

Artiga, S., & Hinton, E. (2018, May). Beyond health care: The role of social determinants in promoting health and health equity. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

This brief provides an overview of social determinants of health and emerging initiatives to address them. It shows: 1) social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care; 2) there are a growing number of initiatives to address… Read more »

American Hospital Association. (2019, January). Medicaid financing for interventions that address social determinants of health. Chicago, IL: Author.

This paper is intended to inform hospitals and health systems about these opportunities as they work with state Medicaid agencies, policymakers and health plans on ways to make financial support available for promising interventions. Medicaid financing can be an important source of support, though it is only one part of the puzzle. This paper identifies… Read more »

Amarasingham, R., Xie, B., Karam, A., Nguyen, N., & Kapoor, B. (2018, January 5). Using community partnerships to integrate health and social services for high-need, high-cost patients. Washington, DC: The Commonwealth Fund.

This brief profiles and classifies burgeoning community-level efforts to integrate the activities of disparate social service organizations with local health care delivery systems in order to identify common challenges and solutions to address the challenges. A mixed-methods approach, including literature search, surveys, and semi-structured interviews with program leaders, and consultation with expert panels was used…. Read more »

Hacke, R., Deane, K.G., & Schwarz, D. (2017, March). Improving community health by strengthening community investment. Cambridge, MA: Center for Community Investment.

This brief examines how community investment community Investment, as a sector, positions itself to confront social determinants of health deficiencies that are the result of market failures. The authors conducted hundreds of interviews with stakeholders from community organizations, government agencies, foundations, banks, and nonprofits. Additionally, a literature review was conducted that looked more broadly at… Read more »

Dodd, S.J., Ruffins, J. & Arzola, D. (2018). Improving health while saving money: Lessons learned from a supportive housing program for young adults with HIV. Sexual Research and Social Policy, 15(2), 163-171. Sex Res Soc Policy.15: 163.

This article presents findings of a program evaluation of the Bailey House Success Through Accessing Rental Assistance and Support (STARS) Program, a 20-unit scatter-site permanent supportive housing program for homeless or unstably housed HIV-positive young adults ages 18–24. A harm reduction and strength-based approach is utilized to connect HIV+ individuals with medical care and other… Read more »

Oftelie, A.M. (2014). The Human Services Value Curve: A Framework for Improved Human Services Outcomes, Value and Legitimacy. Cambridge, MA: Leadership for a Networked World.

To help human services leaders make progress on their capacity-building journey, Leadership for a Networked World reviewed best practices and worked with practitioners as part of the Human Services Summit at Harvard University to develop a framework referred to as the “Human Services Value Curve.” As a human services organization advances along the curve, the… Read more »

The Kresge Foundation. (2017). Integration of health and human services [Website].

This website provides and overview of one area of the Kresge Foundation’s Health Program, the integration of health and human services. This program area seeks to: demonstrate models of integration that impact the health and well-being of families and children through an efficient, effective and seamless system of service; build infrastructure, policies and practices within… Read more »

National Human Services Assembly. (2018). National Reframing Human Services Initiative [Website].

This is the website of the National Reframing Human Services Initiative. This initiative seeks to build broader and deeper public support for human services so that everyone has the opportunity to reach their full potential. The website provides resources related to the initiative, including tools, publications, implementation guides to help to help organizations, associations, and… Read more »

The Annie E. Casey Foundation. (2014). Creating opportunity for families: A two-generation approach. Baltimore, MD: Author.

Nearly half of the nation’s families with young children struggle to make ends meet. This policy report makes the case for creating opportunity for families by addressing the needs of parents and their children simultaneously. Creating Opportunity for Families: A Two-Generation Approach describes a new approach to reducing poverty, which calls for connecting low-income families… Read more »

Waters, R., & Buchanan, A. (2017). An exploration of person-centered concepts in human services: A thematic analysis of the literature. Health Policy, 121(10), 1031-1039. 

Being ‘person-centered’ in the delivery of health and human services has become synonymous with quality care, and it is a core feature of policy reform in Australia and other Western countries. This research aimed to identify the uses, definitions and characteristics of the term ‘person-centered’ in the aging, mental health and disability literature. A thematic… Read more »

Never, B. (2016). The changing context of nonprofit management in the United States. In D.O. Renz & R.D. Herman (Eds.), The Jossey-Bass handbook of nonprofit leadership and management 4th Edition (80-101). San Francisco: John-Wiley & Sons.

This chapter provides a foundation for understanding the nature of the nonprofit sector in America today, explain the context within which the sector operates, and offer some observations about how the sector may continue to evolve and change in the coming five to ten years. One of the most important insights about the American nonprofit… Read more »

BlueCross BlueShield Institute. (2017). Annual benefit report 2017. Author.

This annual report describes how BlueCross BlueShield Institute is addressing social determinants of health, specifically in the realm of transportations. BCBS Institute developed a model of transportation as a critical element of population health management. BCBS Institute created the BCBS Institute created the Community Health Management Hub Transportation Management Application. BCBS Institute utilized the Hub… Read more »

American Public Human Services Association. (2018). National Collaborative for Integration of Health and Human Services [Website].

This is the website for the National Collaborative for Integration of Health and Human Services. APHSA’s National Collaborative for Integration of Health and Human Services (National Collaborative) drives innovation through the horizontal integration of the health and human services system. It promotes a system anchored in seamless, streamlined information exchange, shared services and coordinated care… Read more »

Nichols, L.M., & Taylor, L.A. (2018). Social determinants as public goods: A new approach to financing key investments in healthy communities. Health Affairs, 37(8), 1223-1230.

This article argues that underinvestment in social determinants of health stems from the fact that such investments are in effect public goods, and thus benefits cannot be efficiently limited to those who pay for them—which makes it more difficult to capture return on investment. Drawing on lesser-known economic models and available data, this article shows… Read more »

McGuire, J., Ranade, R., & Shellenberger, K. (2018). Paying for population health: Case studies on the role of the health system in addressing social determinants of health. Washington, DC: Academy Health.

This report includes four case studies of sites where health systems were actively involved in addressing social determinants of health including housing, employment, education, food security, transportation, healthy behaviors, and neighborhood and built environment. Case studies focus on interventions for medically complex homeless individuals, people with chronic diseases, pregnant women and their newborns, and uninsured… Read more »

Brown, C., & Cintron, L. (2016). The New Brunswick Ciclovia evaluation report. New Brunswick, NJ: The Alan M. Voorhees Transportation Center.

This report documents and evaluates the overall success and effectiveness of New Brunswick’s first Ciclovia, an event where roads are closed to motorized vehicle to create a free-form event that welcomes participants of all ages and abilities to enjoy physical activity and recreation in a safe and inclusive environment. The research team collected data by… Read more »

Zuckerman, D. (2013). Hospitals building healthier communities: Embracing the anchor mission. Takoma, MD: The Democracy Collaborative.

This report argues that hospitals are well situated to lead community revitalization strategies by embracing their “anchor institution mission.” Such a strategy: 1) aligns with a hospital’s commitment to promote health, 2) generates economic returns to both the community and institution, 3) helps satisfy its community benefit requirements to the federal government, and 4) provides… Read more »