Path to Prioritizing SDoH in Whole Person Chronic Care: Q&A series featuring Shannon Saksewski, LMSW, MBA and Erin Brigham-Gray, MPH, CPHQ

Delivering meaningful and compassionate care requires addressing the social factors that significantly impact individuals living with complex diabetes and chronic conditions. By understanding and prioritizing social determinants of health (SDoH), we can better respond to the unique challenges patients face. This approach involves collaboration across multiple sectors to address the systemic, environmental, and social influences that shape patient well-being.

For this edition of our SDoH Q&A series, we are privileged to sit down with two experts driving progress in this space—Shannon Saksewski, LMSW, MBA, Complex Health Strategy and Policy Advisor at CareSource, and Erin Brigham-Gray, MPH, CPHQ, Senior Director of Quality & Population Health at CareSource.

Together, they explore strategies for leveraging community partnerships, Medicaid managed care organizations (MCOs), and tools like social care screenings and waivers to support vulnerable populations. Their thoughtful discussion also offers insights into the future of healthcare, emphasizing the integration of physical, behavioral, and social care, enhanced data alignment, and community investments. Read on to learn how these efforts can help reduce disparities and transform care delivery for 2025 and beyond.

Q: Can you please tell us about the important work you lead at CareSource?

Erin: My role at CareSource is to make sure our organization gets better at delivering healthcare by finding ways to improve processes, fix problems, and ensure we meet high standards. I also work to improve the overall health of our population by identifying health trends and developing programs that prevent illness and promote well-being. My job is very collaborative with state agencies and stakeholders, both internally and externally.

Shannon: My work is focused on policy and strategy related to population health, social care, and equity, especially as these concepts relate to complex populations. I am particularly interested in how data, technology, and people can — and do — come together to advance health for all people.

Q: How does your work support patients experiencing SDoH-specific challenges?

Erin: My role is very data-driven (both qualitative and quantitative) to understand what are the drivers of health outcomes within populations. Utilizing this data, I am able to understand where there may be health disparities between populations. Using the data, I also work with stakeholders to determine the best strategies to improve the health of the populations, which includes strategies to address social determinants of health (SDoH). The work I do is in alignment with clinical best practices and ensures that our health plan, contracted providers, and community partners understand our members while also meeting federal and state compliance, like improving health equity.

Shannon: My role is not member-facing, but my hope is that my work is impactful to our members, their communities, and our member-facing staff. My work, generally, falls into a few different categories:?

• Operational improvements: Identifying process gaps and inefficiencies and working across the organization to address issues;
• Policy and data interpretation: State and federal regulations are extremely impactful to the work we do at CareSource, so it is critical to understand the ever-changing regulatory landscape around Medicaid, SDoH, health-related social needs (HRSN), and equity to develop innovative ways to improve our work in these areas. Likewise, it is important to utilize both internal and external data to understand disparities, geographic areas most impacted by health and/or social concerns, and existing community and health resources and
• Strategy development: Based on policy and data interpretation efforts, I then work with stakeholders from both within and outside CareSource to create strategies and solutions to address health disparities, including those focused on basic needs and member empowerment.?

Q: Through your work at CareSource, how do you see SDoH impacting patients living specifically with diabetes today?

Erin: Through qualitative information gathered from our members, community partners, providers, and staff, we see and understand that SDoH impacts people living with diabetes through multiple domains. I am going to reference the Healthy People domains of SDoH to explain:

1. Economic stability: Members may not have enough money to support their basic needs. For instance, they may not be able to afford the food that they need to manage their diabetes, afford their medication, or pay for housing or other basic necessities, which then causes them to put their health on the back burner. Because of this, our organization, like others, has initiated strategies to help members get access to healthy foods and provide nutrition education.?
2. Education access and quality: Educational attainment is directly correlated with health outcomes — the higher a person’s educational attainment, the more likely they are to have better outcomes in chronic conditions like diabetes. Many individuals who are marginalized may not have had the opportunity to reach a higher level of education based on where they live (or grew up), therefore impacting their ability to get certain jobs to make them more economically stable. This starts early when individuals are children, well before many are diagnosed with diabetes.
3. Healthcare access and quality: This is one of the main aspects of our role as a managed care plan. We are helping to provide access to healthcare; however, providing individuals with access is not enough. There are individuals with diabetes who may live in rural or Appalachian areas and have to drive 45 minutes or more to see a doctor! If they do not have money to maintain or put gas in their car, how are they expected to get to the doctor? Transportation is a common topic of discussion for our health plan. It is well known in the peer-reviewed literature and was emphasized during the pandemic that marginalized individuals, including those of certain socioeconomic status or racial/ethnic groups, received poor quality care.
4. Neighborhood and built environment: Where a person lives impacts their outcomes. Is their environment safe? Walkable? Do they have access to food in their neighborhood?
5. Social and community context: For this example, I am going to focus on those who are 65+ years of age with diabetes. Some individuals do not have family or friends to support them. Our HRA helps us to identify if individuals are lonely or have other SDoH needs and/or would derive value from support and connection with others like them.

Shannon: Many of our members struggle with HRSN. These needs impact how an individual can manage diabetes. For our members with diabetes, it is critical to ensure that they have access to medically and culturally appropriate meals. Likewise, access to meals implies the need for safe and stable housing to enable food storage, cooking, and consumption. In addition, to properly manage any chronic condition, one must understand how to do so. This requires the ability to attend appointments consistently and in a timely manner, which requires access to transportation. Of course, learning about one’s condition and then acting on that knowledge becomes deprioritized if one is actively in survival mode — actively navigating complex housing, food, and transportation systems. All of this to say: Social needs are interrelated and critically impactful to our members with diabetes.?

Q: Are there any specific approaches you utilize or have seen others utilize that have shown the positive impact of prioritizing SDOH needs for people living with chronic diseases?

Erin: Leveraging trusted organizations/community partners has been very successful. To name a few based on recent examples: NCUS in Franklin County, Ohio; El Centro in Lorain County, OH; and ICAN in collaboration with the YMCA. Partnering with these agencies has brought diabetes resources, including education, nutrition support, access to care, and engagement with our health plan care management teams, right where members are — specifically members who are more vulnerable or more at risk of having poor outcomes with their diabetes. Collaboration across health plans within the state of Ohio to share these best practices or fund community organizations has also shown a positive impact on improving diabetes management through best practices such as DSME or CGM utilization. It has also helped to decrease the administrative burden to providers for that alignment and has built trust between multiple sectors of healthcare, including the community.

Shannon: As a starting point, we make a concerted effort to ensure that our members understand that we are here to help them address their needs by 1) conducting a social care screening at least annually and 2) creating pathways internally, as well as community-based pathways, for members to reach us to request support at any time. Once we know about a need, our social care teams can quickly reach out to members with supportive services.?

With the expansion of Section 1115 demonstration waivers, states and payers are now more empowered than ever to ensure that people receive and maintain the care they need. We leverage these waivers, coupled with specific proprietary tools, benefits, and teams, to ensure our members can access physical, behavioral, and social care resources. Especially for those who live with one or more complex diagnoses — including diabetes — we rely on the expertise of community health workers (CHWs) and peer support specialists to help our members navigate the multiple complex systems in their communities.?

Q: If people are not receiving the care they need related to SDoH, where do you recommend they go for support beyond their primary care provider and team of care specialists?

Erin and Shannon: The answer to this question will vary by community and an individual’s specific needs. In general, though, anyone who is insured by a Medicaid managed care organization (MCO) should consider their insurer a resource to support their access to social care needs. MCOs employ teams of care managers, CHWs, and/or peer supporters to ensure that all members have access to the physical, behavioral, and social care resources they need. In many cases, social care resources are made available through mandatory transportation benefits, voluntary value-added benefits, and in-lieu-of-services (ILOS).?

Additionally:?

• Most communities have access to the referral and support services of United Way/211 and findhelp.org. These organizations bring together the resources within communities and make them available free of charge.?
• A national, searchable resource for food access is Feeding America, which partners with many local food banks and food pantries.?
• Faith organizations often support their communities by offering food pantries, transportation, and other services.?

Q: Are there any specific SDoH initiatives that CareSource plans to prioritize or invest more in next year?

Erin and Shannon: While we can’t speak to specifics, what we can say is that CareSource is committed to investing in the communities we serve and to addressing the disparities our members experience in ways that are approachable, accessible, and culturally relevant.?

Q: What is one prediction for 2025 — or hope, even — that you have for improvements specific to SDoH for patients living with chronic diseases like diabetes?

Erin: Continued alignment of healthcare metrics across different organizations. I wish there were better data integration; however, that will take more time! Having just attended a national quality conference discussing quality, health equity, and population health, I know the U.S. healthcare system is going to get closer.

Shannon: One hope that I have for 2025, specifically related to those with chronic conditions such as diabetes, is that we collectively work toward the integration of physical, behavioral, and social care. Very often, the healthcare industry overall silos physical and behavioral healthcare, despite concerted efforts to bring them together. When I hear talk of integration, it is rare for social care to be included in that concept. However, social care directly impacts both physical and behavioral health (and vice versa). Specifically, I would love to see more health practices offer onsite CHWs and peer supporters to help individuals understand that care for their particular needs is available and then help them access those services. Adjacent to this, I hope that payers are at the table as partners to contribute to this ongoing work.?