Top 10 SDOH Sessions at HIMSS20

Social needs have long been an important concern in the healthcare space, but only in the past five years have they exploded as a full-fledged trend. The trend isn’t going away anytime soon. Here at Activate Care, we believe the industry is now five years into a 20-year business cycle what we call the Era of SDOH Care. Healthcare industry stakeholders and their partners in social services who are looking to improve population health outcomes and reduce total cost of care need to understand what SDOH care means today in order to successfully find a place within this new dynamic.

At HIMSS20 this year, there are nearly fifty sessions and learning opportunities centered on the social determinants of health, health-related social needs, and healthcare's trend towards deeper integration with social services. Visit Activate Care at Booth #6772 and our SDOH Kiosk in the Interoperability Marketplace to learn more about our all-in-one platform for community coordination, referral management, and data and analytics for SDOH care. We also encourage you to check out these recommended learning sessions.


A Policy Perspective: Coordinating Systems to Address Social Determinants of Health

Wednesday, March 11 – 8:30am-9:30am – W300

As states, municipalities, health plans and providers increasingly design programs to address social determinants of health and measure their programs’ impact, the need for reliable, standardized and secure data grows. Government officials including Activate Care customer Charis Baz from the Marin County Department of Health and Human Services in Northern California – will share key considerations in leveraging social determinants data and will highlight innovative best practices in these areas.

  • Charis Baz, MPH, Senior Analyst, Whole Person Care, Marin County Department of Health and Human Services
  • Dr. Elizabeth Tilson, State Health Director, State of North Carolina
  • Dr. Priit Tohver, Advisor for e-Services Innovation, Estonia Ministry of Social Affairs


Leveraging HIE in SDOH Engagement and Reduced ED Utilization

Wednesday, March 11 – 11:30am-12:30pm – W304A

The Centers for Medicare and Medicaid Services (CMS) and the Michigan Department of Health and Human Services (MDHHS) selected the Greater Flint Health Coalition (GFHC), to implement a State Innovation Model (SIM) initiative. GFHC designed a clinical-community linkage model to meet the population health needs of 41,000 Medicaid qualified adults. The collaborative effort engaged local physician organizations, Medicaid health plans, hospitals, specialty hubs, and a collective of community and social service organizations. Great Lakes Health Connect (GLHC), the leading HIE in Michigan, became a partner in this effort to provide custom reporting on targeted populations, enhance communications, and streamline processing among the various collaborating entities. This presentation will provide an overview of the process involved in designing and deploying the Genesee Community Health Innovation Region as part of Michigan’s State Innovation Model Initiative. Specific opportunities, challenges, and outcomes to date will be discussed.

  • Kirk Smith, President & CEO, Greater Flint Health Coalition
  • Doug Dietzman, CEO, Great Lakes Health Connect

Navigating America’s Hidden Healthcare Crisis: Homelessness

Wednesday, March 11 – 1-2pm – W330A

More than half a million Americans are homeless, and the impact is being felt in hospital emergency departments (EDs) across the country. New state laws demand hospital EDs to take steps to more safely discharge homeless patients. But how can ED staff ensure a safe discharge when these patients are reluctant to share their lack of housing? While counties have resources to help homeless patients, few have the infrastructure to comply with these laws. During this presentation, Ronn Berrol, MD, emergency department medical director for Alta Bates Summit Medical Center–Oakland, will explore how to use the resources available in your community to make a real impact on patients’ lives, rather than simply being compliant with the law. He will share the changes the hospital has made, in an effort to provide actionable insight for ED doctors at the point of care. It’s an approach that reduces costs and contributes to better care outcomes for vulnerable patients.

  • Dr. Ronn Berrol, Medical Director, Alta Bates Summit Medical Center

Integrating Social Determinants Into an HIE Network

Wednesday, March 11 – 1-2pm – W209C

Given the growing need to regularly integrate clinical, social, genetic, environmental, and other data on individuals and populations, the Regenstrief Institute Center for Biomedical Informatics is creating the Indiana Network for Population Health (INPH). The INPH is an information infrastructure that will provide a data platform and governance mechanism to facilitate gathering, managing, sharing, and using population health data across a wide set of stakeholders for both practice and research. The platform is initially being constructed to support immediate use in response to the opioid crisis, yet the platform is designed to accommodate other high priority population health use cases. The presentation will focus on how the infrastructure incorporates data on the social determinants of health into an existing environment that facilitates information exchange across hospitals, clinics, payers, laboratories, and other healthcare organizations.

  • Brian Dixon, Director of Public Health Informatics, Regenstrief Institute

Swimming Upstream: What Will It Take to Integrate the Social Determinants of Health Into Healthcare?

Wednesday, March 11 – 2:30-3:30pm – Booth 8300, Education Theater

Recently, there has been overwhelming recognition that the conditions in which people are born, work, learn, play, and live, otherwise known as the, Social Determinants of Health (SDOH), account for a significant percentage of health outcomes. SDOH is a topic dominating the conversations of major healthcare players who are looking to improve patient outcomes while lowering costs, and embracing the shift to value-based care. Through this dialogue, it has become clear that trying to formalize a clinical pursuit of meaningful integration of SDOH is extremely challenging. This panel will examine current national efforts around SDOH data integration and discuss the successes, failures, challenges, and opportunities for leveraging this information to inform care delivery.

  • Sheila Shapiro, SVP Strategic National Partnerships, UnitedHealthcare
  • Evelyn Gallego, Founder and CEO, EMI Advisors
  • Andrew Hamilton, RN, CIO, Alliance of Chicago Community Health Services

The Gravity Project: A Social Determinants of Health Data Coding Collaborative

Wednesday, March 11 – 4-5pm – W206A

The influence of social determinants on health outcomes is increasingly recognized in emerging payment reform programs, federal and state-based policies, and information technology initiatives. The growing awareness of how SDH shapes health has contributed to efforts to address actionable socioeconomic risk factors through the healthcare delivery system. However, the ability to document and address these social risk factors in clinical settings is hampered by the lack of standards available to code and exchange the data. This session will introduce the Gravity Project, an HL7 FHIR Accelerator Project, initiated in May 2019 by the Social Interventions Research and Evaluation Network (SIREN) in partnership with EMI Advisors LLC. The presentation will highlight the project’s approach to consensus-driven development of coded data elements. It will describe key learnings about productive ways to engage communities in defining core data needed for interoperability.

  • Evelyn Gallego, Founder and CEO, EMI Advisors

Changing the Care Dynamic with Real-Time Health Event Alerts

Wednesday, March 11 – 4-5pm – W207C

It is estimated that approximately 80% of serious medical errors involve miscommunication during patient transfers or hand-offs. Automated notifications support providers’ ability to care for their patients and have been proven to improve care coordination and help contain healthcare costs. The Connecticut Department of Social Services implemented Project Notify to improve care coordination and reduce preventable readmissions for Medicaid beneficiaries who have complex care issues and multiple transitions of care. By integrating real-time notifications into the EHR system, which works through the Direct messaging protocol, actionable data is delivered into the provider workflow, enabling greater visibility to the patient's care across the care continuum and improved transitions of care from the inpatient to the ambulatory setting. Greater efficiencies and improved communication contribute to reduced costs and lower administrative burden.

  • Minakshi Tikoo, CEO, REAPm LLC


Urban-to-Rural Medicaid Transformation

Thursday, March 12 – 10-11am – W414D

Medicaid Transformation programs are revolutionizing the delivery of healthcare. They are increasingly focused on developing data-driven ways to address the complex social needs of their populations while driving value-based care. And while each program is unique, there are common threads of Value-Based Payment innovation driving them all. A comparison of the Staten Island Performing Provider System (SI PPS) and Care Compass Network (CCN) DSRIP programs in New York State provides a great example of this. New York State’s $8.2 billion waiver is the largest in the country and NY has long been a DSRIP leader with both the SI PPS and CCN top performers. SI PPS has a tight geography and urban population while CCN is spread across nine counties in the southern part of the state with a wider geography and more rural population with different challenges. But both programs utilize community needs assessment, similar data assets, and a common technology solution to solve health disparities and build scalable, value-based care transformation programs. This session will analyze what SI PPS and CCN have done to be successful and the shared denominators of success in their clinical, social, and substance abuse disorder/behavioral health transformation initiatives. It will include use cases and updated results from both programs.

  • Joseph Conte, PhD, Executive Director, Staten Island Performing Provider System
  • Dr. Raj Lakhanpal, CMO, Spectramedix

Capturing Social Determinants of Health Data Across Community Health Centers

Thursday, March 12 – 11:30am-12:30pm – W304A

Community Health Plan of Washington (CHPW) is a not-for-profit provider-owned plan serving over 300,000 members, primarily Medicaid and Medicare. CHPW’s network includes 20 Community Health Centers (CHCs) that operate more than 130 clinics across the state with more than 2,500 primary care providers, 14,000 specialists, and more than 100 hospitals. Since 2011, CHPW and the CHCs have shared claims-based and EHR data via a shared analytics platform. This collaboration allowed CHPW to administer an innovative P4P program, drive value-based payments, run a strong risk documentation program, and support quality initiatives across the network. But with social determinants of health (SDoH) heavily influencing patient outcomes, CHPW wanted to do more to support its providers with broader issues in their communities – and the first step was sharing data. In this session, CHPW explains how to engage and partner with providers to capture and work with SDoH data to enable community partners and CHCs to mobilize community-based resources.

  • Jennifer Polello, Director, Clinical Integration & SDOH, Community Health Plan of Washington

Analytics for Good: Using SDOH to Improve Infant Mortality

Thursday, March 12 – 4-5pm – W414A

African-American babies in Ohio are more than three times as likely to die before their first birthday, compared with white babies. Instead of pursuing traditional top-down attempts to change at-risk, mother behaviors, Ohio pursued a social determinants of health (SDOH) approach. It combines cross-agency data sharing and collaboration opportunities with intelligent analytics, to achieve better birth and infant mortality outcomes. Led by fast-moving cross-disciplinary teams, the approach incorporated Human-Centered Service Design techniques with appropriate ethical oversight and governance. The initiative sought to answer three questions: which mothers and infants face the greatest risk of infant death; which will benefit the most from participating in interventions; and which interventions will save the most lives? In just three months, Ohio created a first-of-its-kind, 360-degree view of the at-risk mothers, prioritized about 250,000 such cases, and prescribed targeted interventions.

  • Silas Buchanan, CEO, Our Healthy Community
  • Terry Hemken, Managing Director, Accenture


HIMMS promo-01