Problems Living Alone 3rd Most Reported SDOH

Medicare defines Health Equity?as the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, living conditions, geography, preferred language, or other factors that affect access to care and health outcomes. CMS Health Equity Programs and Resources

ACO REACH participants and other value-based care organizations must prepare and submit to Medicare a Health Equity plan of action to address social determinants of health (SDOH).

• ?The purpose of the Health Equity Plan is to identify underserved patients within the REACH ACO’s beneficiary population and implement initiatives to measurably reduce health disparities.? These plans were recently submitted to Medicare.
• A template was made available that required detailed information regarding the underserved populations served by the REACH ACO, the proposed interventions including actions steps, and outcome measures.

The Center for Health Disparities Research at the University of Wisconsin School of Medicine and Public Health maintains an Area Deprivation Map that scores geographic areas using ADI scores lowest to highest.?? ADI or Area Deprivation Index scores ranks neighborhoods by socioeconomic disadvantage.? This provides a great resource to value-based care organizations in identifying neighborhoods with the highest need.

Medicare Z codes are the methodology to report and track SDOH, such as problems related to living alone or isolation.

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The Z codes that represented the largest shares of all Z codes in 2019:

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Survey

In a recent survey we conducted the overwhelming response to the top obstacles to implementing a health equity plan was how to control the costs of implementation as such programs generate no revenue for the value-based care organization to financially support the program.

Survey respondents indicated their organizations are approaching health equity in a variety of ways:

• Print brochures or fliers outlining available community services such as shelters and transportation available at clinic and hospital entrances and during treatment encounters.? Survey respondents indicated this was less costly option but did not have data on its effectiveness.
• Websites listing available community services such as meals, literacy, or housing.? Survey respondents indicated this was also a less costly option but did not have data on its effectiveness.
• Comprehensive and coordinated staff and provider efforts during wellness visits to screen and introduce social services to the patient at the point of care via print or web media resources.? Survey respondents indicated this seemed to be the most effective method as they experienced immediate positive results, but it was also the costliest option due to staff time and resources.? About 72% of respondents indicated their health equity processes were only available during a treatment encounter classified as an Annual Wellness Visits (AWVs) as the reimbursement and time allocated financially supported the programs objectives.

We often think of health equity as homelessness, lack of transportation, or lack of food resources.? However according to Medicare, problems living alone is in the top three social determinant Z codes reported.

?Living alone contributes to a general lack of socialization, isolation, and conditions such as depression and anxiety. My mother recently moved into my home, so I as well was searching for ways to combat isolation and trying to find offerings for social activity as even having a family member in the home was not enough due to work commitments.

I was recently introduced to MyHealthAngel virtual event offerings.? Virtual events are scheduled weekly and include a variety of relevant topics, including health & wellness, life improvement, travel, cooking, art, history, and more MyHealthAngel will coordinate with value-based care organizations to customize and white label branded events focused on chronic conditions such as diabetes or specific benefits, such as transportation offerings.

As value-based care organizations search for effective and efficient means to put their health equity plans into action, MyHealthAngel is a resource to consider.

Kris Gates, [email protected]