learning objectives - starchapter€¦ · others involved with the system; •respondsby...

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Mastery of the Social Determinants of Health:

Case Management’s Next Frontier

Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEFS Supervision Strategies, LLC

Economic Stability Education Health &

Health CareNeighborhood

& Built Environment

Social & Community

Context

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Learning ObjectivesDefine the Social Determinants of Health (SDoH)

Discuss and apply reimbursement methods to practice

Use varied assessment tools across populations

Understand traditional and new faces of SDoH

Apply content to relevant industry standards and codes

Be knowledgeable of model programs and resources

Discuss the ethical impact of bias in case managing SDoH populations.EFS Supervision Strategies, LLC © 2020

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Disclosure & Disclaimer

There are no potential conflicts of interest contained in the information provided in

this presentation. All material is the opinion of this presenter or cited to source and/or

authorityAny products referred to during this

presentation are for the sole purpose of example only and should not be taken as

product endorsement.EFS Supervision Strategies, LLC © 2020

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Continuing EducationThis program has been pre-approved by The

Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. The course is

approved for 2.0 Ethics CEUs.

EFS Supervision Strategies, LLC © 2020

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What Are We Talking About?Social Determinants of Health (SDoH):


the conditions in which people are born, grow, live, work and age…..

shaped by the distribution of money,

power, and other societal resources at global, national and

local levels(World Health Organization, 2016a)

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What Are We Talking AboutEconomic Stability

Education Health & Health Care

Neighborhood & Built

Environment

Social & Community

Context

Poverty High School Graduation

Access to Health Care

Access to Healthy Foods

Social Cohesion

Employment Enrollment in HigherEducation

Access to Primary Care

Quality of Housing

Civic Participation

Food Security Language & Literacy

Health Literacy Crime & Violence

Perceptions of Discrimination & Equality

Housing Stability Early Childhood Education & Development

Environmental Condition

Incarceration/Institutionalization

(HealthyPeople 2020; 2019)EFS Supervision Strategies, LLC © 2020

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Structural and Intermediary Determinants (Bryant, et. al. 2015; Guinto, 2012; Rajda and George, 2009, Solar and Irwin, 2010)

Structural Determinants-Socio-political contexts reinforcing stratification

• Governance• Macroeconomic policies• Social policies• Public policies• Culture and societal values

Intermediary Determinants-

Factors shaping health choices/outcomes

• Material circumstances• Behaviors and biological factors• Intergenerational factors• Psychosocial factors• Health system quality

Impact on health equity & well being


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Are the SDoH New?


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Foundational perspectives of Social Determinants of Health (Solar and Irwin, 2010)

Social selection

Social causation

Life course


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Who Are We Talking About?• Petra, a 55 year old woman who resides in a rent stabilized

apartment in Midlothian. The once middle class community has been infiltrated by crime, and poverty

• Most of Petra’s neighbors live below the poverty line, $12,490 annually for one person, and $25,750 for a family of 4.

• Petra chronic illnesses prompt frequent Emergency Department visits; 4 in as many months for CHF exacerbation.

• Dr. Smyth, is worried Petra’s diet is the culprit: ‘My grocery store closed last year, and the local 7/11 doesn’t have anything on that diet the nutritionist in the ED gave me. I buy the healthiest things they have there’.

• Your thoughts ??


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Who Are We Talking About?• Mary is an 88 year old woman who lives in Suffolk, VA. A widow for

10 years, Mary lives on Social Security of $980 a month. She planned on her husband’s pension, but the company filed for bankruptcy.

• Her Social Security covers taxes, food, insurance, and other expenses (e.g. medication co-pays, dental care, out of network costs for her rheumatologist; the provider in her region recently retired and another MD has not been found to replace him.)

• Mary eats 2 meals most days to extend her food supply. Some days she eats one large meal, supplemented by tea and fruit.

• Mary has two sons: one died in an accident 5 years ago and she is estranged from the other. Many peers have also died.

• She spends her days in watching TV and reading…..• You wonder……???


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Residents of rural health

regions

The New Face of the SDoH….

Victims of natural & man-made disasters

Persons facing sudden shifts in financial status, loss of income from business closures, government shutdowns & older adults who lose pensions.

Women impacted by domestic violence & gender

discrimination

Victims of social isolation

Members of the LGBTQ community facing

societal stigma & family abandonment.

Children and adults living with

disabilities

Victims of trauma

Homeless veterans


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Who Else Are We Talking About?• Leah is a 38 year old woman who lived on a farm in Lynchburg,

VA. Married for 15 years to Damien, Leah recently fled from her home after years of domestic violence.

• Leah has two children, Nadine and Max who are 7 and 14 respectively, and exposed to their father’s physical and verbal outbursts.

• Leah, and Nadine are diagnosed with asthma; Nadine had two recent ED visits for nebulizer treatments.

• Damien isolated Leah during their marriage, so she has no friends. Leah has been living on the street, going from shelter to shelter.

• Leah is fearful Damien will locate her and refuses to apply for jobs where she has to give her Social Security #. In exchange for food and place to sleep, Leah cleans a diner at night.


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Who Are We Talking About?

County Health Rankings, 2017

Overall Rankings in Health Outcomes


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Who Are We Talking About?

County Health Rankings, 2017

Overall Rankings in Health Factors


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ACEs Risk Factors (Centers for Disease Control and

Prevention, 2018b)

• Alcoholism/alcohol abuse• Chronic obstructive

pulmonary disease• Depression• Fetal death• Health-related quality of life• Illicit drug use• Ischemic heart disease• Liver disease• Poor work performance• Financial stress• Risk intimate partner violence

• Multiple sexual partners• Sexually transmitted diseases• Smoking • Suicide attempts• Unintended pregnancies• Early initiation smoking• Early initiation sexual activity• Adolescent pregnancy• Risk for sexual violence• Poor academic achievement


Increased ACEs=increased risk of health/behavioral

health issues

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ACE Pyramid-Impact Adverse Childhood Experiences: Health and Well-Being over the Lifespan

(Adapted Centers for Disease Control and Prevention, 2018)

Early death

Disease, disability, social

problems

Adoption of health-risk behaviors

Social, emotional, cognitive impairment

Disrupted neurodevelopment

Adverse childhood experiences

Exposure of children to trauma impacts health over the life course

Conception

Death


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1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid you might be physically hurt? and2. ……….Push, grab, slap, or throw something at you? or hit you so hard you had marks or were injured?3. Did an adult or person at least 5 years older than you ever… Touch, fondle, orhave you touch their body in a sexual way? or Attempt or actually have oral, anal, orvaginal intercourse with you?4. Did you often or very often feel… No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?5. Did you often or very often feel … You didn’t have enough to eat, had to weardirty clothes, and had no one to protect you? or Your parents were too drunk or highto take care of you or take you to the doctor if you needed it?6. Were your parents ever separated or divorced?7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?8. Did you live with anyone who was a problem drinker, alcoholic, used street drugs?9. Was a household member depressed, mentally ill, or attempt suicide? 10. Did a household member go to prison?

Answer Yes (1 point), or No (0 points)EFS Supervision Strategies, LLC © 2020

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The Common Thread of the SDoH Evokes a Mandate

‘Any effective response to the populations and persons impacted by the SDoH, MUST include a Trauma-Informed Approach to

Care’


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Let’s Talk Trauma-Informed CareTrauma-Informed Approach: A program, organization, or system that:• Realizes widespread impact of trauma and understands potential paths for

recovery;• Recognizes signs and symptoms of trauma in clients, families, staff, and

others involved with the system;• Responds by integrating knowledge about trauma into policies,

procedures, and practices; and• Seeks to actively resist re-traumatization.Six Key Principles of a Trauma-Informed Approach:• Safety• Trustworthiness and Transparency• Peer support• Collaboration and mutuality• Empowerment, voice and choice• Cultural, Historical, and Gender Issues

(SAMHSA, 2019)EFS Supervision Strategies, LLC © 2020

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$200 Billion in

premature deaths

$35 Million in excess

healthcare costs

2017 National Health

Expenditures:$3.6 Trillion

7.4% Medicare

5.8% Medicaid


Why the Alarm?

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Why the Alarm?

86% of current health care spending is

related to chronic conditions

(Sullivan, 2017)

SDoH impacting 60%

of outcomes


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The Social Determinants’ Role in Health

40%

30%

20%

10%

Social Determinants' Role in Health

Socio -eco nom ic

Heal th b ehaviors

Heal thcare

Ph ys ical envi ron ment

(Driver, 2019)


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Why the Alarm?

• Patients with:– higher transportation

access risk: 41% more excess days in the hospital

– higher home instability risk: 32% more likely to exceed the average hospitalization.

(Gooch, 2018)

The SDoH contribute to

>50% of readmissions


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Why the Alarm?Readmissions:• Persons residing in high poverty areas

• Safety Net Hospitals

(Davis, 2015; Reforming Health, 2014; Rice, 2014)

24% more likely to be readmitted

• 20% of Medicare patients discharged is readmitted in < 30 days

• 77% of hospitals with the highest share of low income patients penalized for excessive readmissions


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Why the Alarm?

10. Stroke: $33B9. Asthma: $56B8. Arthritis: $128B7. Obesity: $147B6. Cancer: $171B5. Alzheimer’s Disease: $236B4. Diabetes: $245B3. Alcohol-related health issues: $249B 2. Smoking-related health issues: $300B1. Cardiovascular diseases: $317B

Top 10 most expensive chronic diseases (Beaton, 2017)


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Why the Alarm?Chronic Disease treatment in the Emergency Department

$8.3 billion in costs

30% of visits unnecessary

4.3 Million Preventable Visits

(Castelluci, 2019; Premier, 2019) EFS Supervision Strategies, LLC © 2020

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What About Digital Divide?


Portal/remote health access significantly lower across race, gender, & socioeconomic status

Lower electronic health record adoption for non-Hispanic black vs. non-Hispanic white patients.

Less personal health record registration by Black vs. White managed care subscribers

Limited to poor quality WIFI access

Outdated mobile devices, browsers limit functionality

Generational & population technology literacy gap

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Behavioral HealthMembers of racial and ethnic minority groups are:• less likely to have access to mental health

services, and• use community mental health far less• more likely to obtain needed care from

emergency rooms, hospitalizations, and• Receive lower quality care

Why the Alarm?

(Alegria, et. al, 2008; Samnaliev, McGovern and Clark, 2009; National Institute of Mental Health, 2016; Wang, et. al, 2005)


Mental health is the biggest driver of unnecessary ED visits: • ED Costs for patients with

psychiatric needs $1,198-$2,264 per visit

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Medicaid Expansion (Commonwealth Fund, 2020)


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• Commission for Case Management Certification (2015) Professional Code of Conduct for Case Managers, Mount Laurel, NJ: Author

• County Health Rankings (2019) RI, 2016 Retrieved January 14, 2019 from http://www.countyhealthrankings.org/app/rhode-island/2018/overview

• Commonwealth Fund (2020, July 31) Maps: Medicaid Expansion and Work Requirements, Retrieved July 31, 2019 from https://www.commonwealthfund.org/publications/maps-and-interactives/2019/jul/status-medicaid-expansion-and-work-requirement-waivers

• Driver, T. (2019) How social determinants of health data can provide actionable insights, Health Data Management, Retrieved January 14, 2019 from https://www.healthdatamanagement.com/opinion/how-social-determinants-data-can-provide-actionable-insights

• Fink-Samnick, E. (2019) The Social Determinants of Health: Case Management’s Next Frontier, HCPro; Middleton, MA

• Galewitz, P. (2019) Medicaid Plans Cover Doctor’s Visits, Hospital Care and Now Your GED, Kaiser Health News, Retrieved August 29, 2019 from https://khn.org/news/medicaid-plans-cover-doctors-visits-hospital-care-and-now-your-ged/

• Gooch, K. (2018) SDoH contributes to over ½ of readmissions, October 25, 2018, Beckers Hospital News, https://www.beckershospitalreview.com/population-health/social-determinants-of-health-contributed-to-half-of-hospital-readmissions-study-finds.html


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• Kent, J. (2018, 5, June) Costs Fell by 11% When Payer Addressed Social Determinants of Health, HealthITAnalytics, Retrieved https://healthitanalytics.com/news/costs-fell-by-11-when-payer-addressed-social-determinants-of-health

• Landi, H. (2017, 11, Sept) Survey: Nearly All U.S. Hospitals Use EHRs, CPOE Systems, Healthcare Innovation, Retrieved https://www.hcinnovationgroup.com/clinical-it/news/13029134/survey-nearly-all-us-hospitals-use-ehrs-cpoe-systems

• National Institutes of Mental Health (2016) Minority Health and Mental Health Disparities Program, National Institutes of Health, Retrieved November 28, 2016 from https://www.nimh.nih.gov/about/organization/gmh/minority-health-and-mental-health-disparities-program.shtml#3

• National Association of Social Workers (2018) Code of Ethics, NASW Press, Washington, DC:Author

• Patel, M.R., Pietta, J.D., Resnicow, K., Kowalski-Dobson, T., and Heisler, M. (2016) Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults With Diabetes: Findings From the National Health Interview Survey. Medical Care, August 2016, 54 (8), pg. 796-803,

• Premier (2016) Performance Evaluation: What is Working in Accountable Care Organizations? Premier/Robert Wood Johnson Foundation, Retrieved March 10, 2017 from https://www.premierinc.com/wp-content/uploads/2016/10/What-Is-Working-In-ACOs-Report-10.16.pdf


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• Solar, O., Irwin, A. (2010) A Conceptual Framework for Action on the Social Determinants of Health: Social Determinants of Health Discussion Paper 2 (Policy and Practice) World Health Organization, Geneva

• Rajda, C and George, N. M (2009) The Effect of Education and Literacy Levels on Health Outcomes of the Elderly, The Journal for Nurse Practitioners, 5(2) pg. 115-119, doi.org/10.1016/j.nurpra.2008.08.020

• Reforming Health (2014) Are Readmission Penalties Unfair to Safety Net Hospitals? October 23, 2014, Retrieved November 21, 2016 from https://reforminghealth.org/2014/10/23/are-readmission-penalties-unfair-to-safety-net-hospitals/

• Rice, S (2014a) Safety Net Hospitals Face Socio-economic disadvantages, June 7, 2014, Modern Healthcare, Retrieved November 28, 2016 from http://www.modernhealthcare.com/article/20140607/SUPPLEMENT/306079900

• Rice, S. (2014b) Bill would adjust readmissions for socio-economic factors, June 20, 2014; Modern Healthcare, Retrieved November 21, 2016 from http://www.modernhealthcare.com/article/20140620/NEWS/306209964

• Tahan, H. in Tahan. H and Treiger, T.. (2017) Chapter 12, The Case Management Process, Chapter 12; CMSA Core Curriculum for Case Management, pg. 292-311; Wolters Kluwer Health: Philadelphia

• Treiger, T. and Fink-Samnick, E. (2016) COLLABORATE for Professional Case Management: A Universal Competency Based Paradigm, 1st ed., Wolters Kluwer Health: Philadelphia

• World Health Organization (2016a) Social Determinants of Health, World Health Organization, Retrieved May 19, 2016 from http://www.who.int/social_determinants/sdh_definition/en/

• Zong, J. and Batalova, J. (2017) Frequently Requested Statistics on Immigration in the United States, Migration Information Source: The Online Journal of the Migration Policy Institute, December 29, 2017; Retrieved December 30, 2017 https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states


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http://www.countyhealthrankings.org/app/rhode-island/2018/overview

https://www.commonwealthfund.org/publications/maps-and-interactives/2019/jul/status-medicaid-expansion-and-work-requirement-waivers

https://www.healthdatamanagement.com/opinion/how-social-determinants-data-can-provide-actionable-insights

https://khn.org/news/medicaid-plans-cover-doctors-visits-hospital-care-and-now-your-ged/

https://www.beckershospitalreview.com/population-health/social-determinants-of-health-contributed-to-half-of-hospital-readmissions-study-finds.html

https://healthitanalytics.com/news/costs-fell-by-11-when-payer-addressed-social-determinants-of-health

https://www.hcinnovationgroup.com/clinical-it/news/13029134/survey-nearly-all-us-hospitals-use-ehrs-cpoe-systems

https://www.premierinc.com/wp-content/uploads/2016/10/What-Is-Working-In-ACOs-Report-10.16.pdf

http://www.modernhealthcare.com/article/20140607/SUPPLEMENT/306079900

http://www.modernhealthcare.com/article/20140620/NEWS/306209964

http://www.who.int/social_determinants/sdh_definition/en/

https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states

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