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Healthcare at Home Blog Series: Addressing SDoH with Healthcare at Home

Entering Consumer’s Home Provides Unique Look at SDoH


Throughout our Healthcare at Home blog series, we’ve looked at a variety of topics, including the shifting policy landscape to support healthcare at home, innovative technology accelerating the trend, and major players investing in the space. 

In our previous blog, we took an in-depth look at what social determinants of health are. In this follow-up blog, we will take a much deeper look into how healthcare at home programs can help address social determinants of health and allow providers to offer whole-person care. 

CMS Social Determinants of Health Report Embraced

As discussed in our last blog, social determinants of health are conditions in the places where people reside, work, and learn that affect a variety of health and quality-of-life risks and outcomes. Because SDOH can have a large impact on health, the U.S. Centers for Medicare & Medicaid Services (CMS) took a strong interest in them. In January 2020, CMS released its first report on social determinants of health. 

The report analyzed data on individuals who were at risk of hazardous socioeconomic, physical, and psychological factors. By analyzing “Z codes” in ICD-10 diagnostic and billing tools, researchers determined that many issues stemmed from “problems related to living at home.” These link to social determinants of health that are influencing health outcomes, such as lack of transportation, poor access to health services, lack of housing stability, and even unhealthy foods.

The report has been embraced by home health care and social services agencies to better understand how outside forces can impact wellness and patient health outcomes. By getting a more in-depth look at SDoH, providers delivering care in a patient’s home can adapt their care services and provide whole-person care.

Examples of expanded services include home hazard assessments to make homes safer to age in, transportation services to increase access to healthcare and other services, and cooking and nutrition programs to improve diets through healthy foods.

CMS doubled down on the importance of SDoH in January of 2021 as well. On January 7, 2021, they issued guidance to state health officials in regards to the adoption of strategies that address social determinants of health in Medicaid. In the statement, the fee-for-service system was taken to task while the importance of a shift to value-based systems that incentivize quality, whole-person care was stressed.

CMS believes the evidence is clear and that social determinants of health like access to stable housing, nutritious food, and gainful employment are not strictly medical, but still have a profound impact on health and wellbeing. Backed by the belief that the fee-for-service system inherently limits doctor-patient relationships to what can be accomplished inside the four walls of an office, CMS stressed the importance of states promoting a value-based system that fosters treatment of the whole person and lowers healthcare costs. 

Delivering Healthcare at Home Provides Unique Look into Patient’s Life

The healthcare at home and hospital at home models enable providers a unique look at social determinants of health. Entering a consumer’s home allowed the healthcare provider team a look at diet, relationships, behaviors, and other aspects that can affect health. This enables providers to deliver whole-person care as they can incorporate social determinants of health into their care plan. 

“The person-centered approach to providing high-acuity and quality care in the comfort of a patient’s home has emerged,” said Stephen Parodi, M.D., executive vice president of The Permanente Federation. “Never has it been as clear as it is now to ensure healthcare is focused on the entire patient, where we are able to address both medical and social determinants that have led to a patient’s condition so we can prevent hospitalizations altogether and address a person’s true goal of care.”

Parodi’s Permanente Federation recently announced a major collaborative effort with the Mayo Clinic and an at-home acute care company called Medically Home. They believe their technology-enabled platform will provide opportunities for care providers to visualize the reality of a patient’s home through true community-level care that is inclusive of home nurses, physician’s assistants, and paramedics. With a new lens into the home of consumers, providers can get a deeper look at how social determinants of health like diet, exercise, and housing might be impacting the health outcomes of these individuals. By addressing these newly identified SDoH, providers on the platform can provide whole-person care, which leads to better health outcomes. 

Incorporating SDoH Into Care Plans

As healthcare at home programs continue to expand, it is important that these social determinants of health continue to be considered and addressed in care plans.  Because of their importance, some states have even required the alignment of traditional healthcare with community-based organizations that provide supports needed to address SDoH. 

Pennsylvania is becoming a national leader in the social determinants of health arena.  The Commonwealth recently announced the Resource Information and Services Enterprise or RISE PA program. This is a referral tool that is a collaborative effort between state agencies, counties, local non-profits, community organizations, and social services providers. Developed by Highmark Delaware and Highmark Health Options, the interactive online platform serves as a care coordination system for providers including, health care and social services organizations and a closed-loop referral system.

In addition to serving as a care coordination tool to address individuals’ social determinants of health like employment, child care, transportation, food security, and more, the tool will also gather data. This will be used to help the state better understand the needs of Pennsylvanians and identify service gaps across the state. While the PA Department of Human Services decided to cancel, pause, and reassess the RISE PA tool in its current form, it is for the benefit and longevity of the tool. The PA DHS is optimistic that this pause and review will allow them to determine the right path forward to ensure that RISE PA is a sustainable and successful tool.

Addressing SDoH in healthcare plans is not new. Aunt Bertha, a social determinants of health management platform, was established over a decade ago in 2010. The system allows millions of people in need to find free and reduce cost health and community-based services by US zip code. This includes medical care, food, job training, transportation, and more. 

Aunt Bertha also provides service organizations with advanced tools to support clients. It offers needs assessments, referral tracking, customer support, and more. The system has seen great results. Connect for Health Colorado used the scheduling functionality and 77% of individuals showed up for their appointments. The platform also helped reduce the call volume to the largest foodbank in Washington D.C. by 92% and supported over 1,100 closed-loop referrals in North Carolina. 

The company was also named the top performer in Social Determinants of Health (SDoH) Networks in the 2021 Best in KLAS report. This honor was awarded based on feedback from healthcare organizations in 2021. Currently, Aunt Bertha serves over 200 healthcare organizations and insurers in the United States. 

With the recent success, Aunt Bertha is looking to expand. In June 2021, the company announced it raised $27 million in new funding. This will be used to enhance the free and paid products, and to allow Aunt Bertha to expand its new Marketplace, and provide growing support for social workers, care coordinators, and other helpers connecting people to social services. In addition, on November 1, 2021, Aunt Bertha announced it’s rebranded to findhelp. This shift in name is intended to allow consumers, organizations, and those seeking care to instantly understand the mission of the company. 

With the delivery of healthcare services at home increasing, providers in Pennsylvania and other states will have a unique look into the lives of consumers, thus allowing them to even better understand how SDoH are affecting the health of individuals. By linking this unique look with programs like RISE PA, once it relaunches, and Aunt Bertha/findhelp, providers can incorporate social determinants of health into care plans and improve the health outcomes of consumers. 

Advocate’s Perspective

It is great to see that social determinants of health are being incorporated into health plans. As shown by RISE PA and Aunt Bertha, through the collaboration of health care providers and social services providers, SDoH can be addressed, which results in whole-person care. However, it is important that value-based payment models are tied to healthcare at home services, as the models incentivize providers to take the steps necessary to improve patient health outcomes.  

That’s it for our healthcare at home blog series—for now! In our next blog, we will recap everything we’ve covered in the last eight blogs regarding healthcare at home. We will also take one last look at how value-based payment models are key for continuing to advance healthcare at home programs.


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About the Author

Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).

His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.

mandy sahhar

About the Co-Author

Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.