Module #1: What are the Social Determinants of Health (SDoH)? For more information on TCPI SANs please use this link: http://www.tcpisan.org/

HCDI Overview HCDI-SAN Learning Library: Overview HealthCare Dynamics, International – founded and led by clinicians 25+ years supporting CMS quality and population health programs NICHE: Policy to Practice Strategy focused on health care delivery systems and the quality/cost for vulnerable populations Customized learning and action platforms focused on clinicians, patients and health care systems HCDI-SAN Learning Library: Overview Social Determinants of Health (SDoH) The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities These social factors may also affect the patient’s ability to self-manage and adhere to their shared decisions. Looking at SDoH data can help practitioners better recognize the root causes that affect population health.

Learning Objectives: Social Determinants of Health Upon completing review of this presentation, the participant will be able to: Define the different SDoH Explain how inequities in the SDoH affect health outcomes and influence health disparities Demonstrate knowledge of health equity Expand their knowledge base concerning of resources available to those suffering from SDoH Identify strategies to increase health equity in local communities

Overview: Social Determinants of Health SDoH also refers to the bigger set of forces that shape the conditions of daily life of an individual. These forces can be social norms, culture, social practices, economic policies, developmental agendas along with political systems of any state/nation SDoH are considered as the root cause of our health and disease. Often times it is also known as the ‘cause of the cause’.

HCDI-SAN Social Determinants of Health Goal: Health Equity The HCDI-SAN goal in analyzing the SDoH, is to ensure clinicians, especially those serving vulnerable populations understand Health Equity and the importance of addressing the social determinants of health as they achieve clinical transformation to actively participate in the Quality Payment Program (QPP). We aim to support practices to: Address the social factors that impact clinical outcomes Improve practice care coordination methods Adopt population specific needs Collect REaL data Close the gap between communities and health care delivery systems Improve health promotion and the prevention/ management of chronic diseases Promote culturally and linguistically appropriate person centered care Provide shared decision-making and enhanced access to healthcare services

HCDI-SAN Social Determinants of Health Goal: Health Equity

Social Determinants of Health Goal: Health Equity Across the nation, gaps in health are large, persistent and increasing. Health equity means everyone has a fair and just opportunity to be healthier. It acknowledges that it's hard to be healthy without access to good jobs, homes and schools. It requires a concerted effort to increase opportunities to be healthier for everyone—especially those with the greatest obstacles.

Community Resources: Social Determinants of Health Whether it’s access to food, transportation, financial services or education, addressing social determinants is a critical component of both quality of care and quality of life. Aunt Bertha is deploying this comprehensive approach, powered by technology, to help lead the way for patients in need and the people who serve them. https://www.auntbertha.com/

Learning In Action: “Food For Thought” How might having data on patient SDoH conditions affect how your office coordinates healthcare for patients? How can your practice incorporate SDoH collection and assessment into your workflow? Do you think that SDoH (i.e. food insecurity, transportation, literacy) are common among your patients? Think of a recent patient case in which SDoH might possibly have contributed to a problem or a poor health outcome? What resources are available in your community to help address issues that are caused by SDoH?

Questions? Uchenna Okoli SDoH@hcdi.com 301-552-8803 www.hcdi.com For more information on TCPI SANs please use this link: http://www.tcpisan.org/ 11

Learning & Action Network Acronym Guide: AAPM: Advanced Alternative Payment Models APM: Alternative Payment Models CEHRT: Certified Electronic Health Record Technology CFYH Tool: ‘Caring for Your Health’ Social Determinants Indicator Tool CMS: Centers for Medicare & Medicaid Services HCDI: HealthCare Dynamics International LAN: Learning and Action Network MACRA: Medicare Access and CHIP Reauthorization Act MIPS: Merit Based Incentive Payment System PTN: Practice Transformation Network QPP: Quality Payment Program REaL Data: Race Ethnicity and Language Data SAN: Support and Alignment Network SDoH: Social Determinants of Health TCPI: Transforming Clinical Practices Initiative