Taking on social determinants of health in the COVID era

Gabriel Perna | July 29, 2020

For people whose careers revolve around the impact of social determinants of health (SDOH) on medical outcomes, COVID-19 has unfortunately been a familiar narrative.

“This story has been told over and over again. Vulnerable, marginalized, significantly disabled, black and brown, poor communities experience disproportionately poor access to health services and disproportionately poor health outcomes. And certainly COVID-19 has only reinforced that again and in interesting ways,” says Iyah Romm, CEO of CityBlock Health, a start-up focused on improving the health of underserved urban populations.

Since the earliest days of this pandemic, research has backed up this sentiment. Data from the Centers for Disease Control and Prevention (CDC) and other sources confirm that Black, Hispanic and other ethnic groups have higher rates of COVID-19 deaths, hospitalizations and infections than white Americans. In fact, in America, the COVID-19 infection rate is three times higher in predominantly Black counties than in predominantly white counties, according to research.

Other data has showed higher COVID-19 infection and hospitalization rates for the homeless, as well as those who have greater exposure to smoke, rely on public transportation and live in crowded urban communities. For those in rural areas, COVID-19 has exposed issues around food insecurity, chronic diseases, and an aging population that could potentially strain the health system, researchers say.

“What COVID-19 did is it demonstrated how inextricable social and medical needs are from one another. It has showed this link in a dramatic, very acute way. But for people in the safety net, and even people outside of the safety net, we’ve recognized that link over the last 30-40 years and that’s manifested itself in the health disparities we’ve written about. We need to think of COVID-19 as an acute case that broke the camel’s back, where it’s become a lot more obvious to the general population and policymakers,” says Laura Gottlieb, MD, founding director of the Social Interventions Research and Evaluation Network (SIREN), a national research acceleration and translation institute based out of the University of California at San Francisco.

Health Evolution explored what payers, providers and other organizations are doing to tackle COVID-19 related SDOH and what the future may hold. What initiatives are moving the needle and what challenges have they run into?

Allen Karp, Horizon Blue Cross Blue Shield of NJ

A payer finds SDOH initiative more needed than ever

Horizon Blue Cross Blue Shield of New Jersey was in the midst of major SDOH plans before the pandemic hit, says Allen Karp, the health insurer’s Executive Vice President of Healthcare Management and Transformation. The company was planning on scaling its Horizon Neighbors in Health pilot, which initially launched in Newark in conjunction with Robert Wood Johnson Barnabas Health System, across New Jersey in the spring of 2020.

“The COVID-19 crisis has highlighted the need for us to expand Horizon Neighbors in Health to more communities across the state,” Karp says. “We’ve had to rework many of the elements of the program in accordance with new health and safety protocols.”

For example, part of the initial pilot involves community health workers going into the home of the patient to better understand their medical and social needs. Horizon has had to virtualize that experience in the COVID era. “The Coronavirus pandemic didn’t create disparities in health, but it magnified them by major proportions,” he notes.  

Amid the pandemic, the Horizon Neighbors in Health initiative took another step forward in June. The insurer announced that with a $25 million investment, its teaming up with the Penn Center for Community Health Works to train community health workers to connect with members susceptible to SDOH vulnerabilities. The company’s goal is to reach and enroll 24,000 at-risk residents in three years.

Horizon uses data tools to analyze medical claims data and identify members with multiple comorbidities who are most likely to need care from a SDOH perspective. The community health workers then engage the members and help them utilize various resources and coordinate care, depending on the patient’s specific issue. Engaging members is a critical factor of success in this SDOH initiative and that’s never been more important than during COVID, where patients need to increasingly rely on mail order prescriptions, telehealth, and behavioral health services.

“What we’ve found is the ability to scale this program is difficult unless you have the right partners and unless you have the analytic capabilities to find the most vulnerable patients. We can’t treat everyone in 70 zip codes. Through analytics, we figure out the needs of members down to a [street] block level not just what social issues they have, but the community services that are offered to them.”

Not forgetting SDOH on the frontlines of the pandemic

On the frontlines of the pandemic, the social and racial disparities issue is front and center for provider organizations dealing with COVID-19. As Janice Nevin, MD, CEO of ChristianaCare based in the Mid-Atlantic region, noted in a recent webcast: “The way that COVID has magnified disparities is extraordinary and I think in a way that we can’t ignore. We have to take action and act differently,” she says.

At ChristianaCare, she says the system received funding from the FCC to deploy technology to people in underserved communities. One thing ChristianaCare learned is they had to equip devices with cellular capabilities because of lack of broadband availability.  She says the health systems have to think differently about making connections with underserved communities in the world of COVID-19. Another challenge for health systems is by serving wide range of patient populations across their multistate regions, inequities vary wildly from community to community.

The way that COVID has magnified disparities is extraordinary and I think in a way that we can’t ignore. We have to take action and act differently.

Janice Nevin, MD, ChristianaCare

“We have to think about that as we look to set national policy, and how do you get a clear, a robust and very focused agenda when there are so many differences across our communities? How do you come together to help set that agenda because what is needed in communities across this country varies dramatically? And how can we make sure that we fix it in a way that it doesn’t disparage someone in that journey?” says Susan Turney, MD, CEO of Marshfield Clinic that has locations across Wisconsin.

Along with its health plan partners, Romm’s CityBlock works with dual-eligible Medicaid patients in New York City, Worcester, MA and other underserved communities where there isn’t a lot of access to primary care and behavioral health. He says the failings of the health safety net became obvious immediately upon the arrival of COVID-19.

“The first thing we did is ask people to socially isolate. Many of our patients live in multi-generational family units and some of the family members are service workers. They’re riding public transit every day. We know these structural challenges exist everywhere,” he says.

Like Horizon Blue Cross Blue Shield of NJ, CityBlock also used an algorithm to identify the most vulnerable patients across their population. They also created a COVID-19 screening tool that was geared towards patients in underserved communities to understand their most fundamental needs. On the direct programming side, Romm says CityBlock did four major things:

Built out a community paramedicine program to deliver in-person care. Within a matter of weeks, Romm says they hired paramedic clinicians to do urgent, in-home clinical response with the supervision of a physician via telemedicine.

Built out a high-risk housing program to help temporarily move members who were living in a setting with increased risk to COVID exposure.

Developed a volunteer food delivery program to help stretch the delivery capabilities for low-income people who couldn’t get to a grocery store.

Ramped up virtualized programming. This not only included the increased use of telehealth services for medical care, but they also created virtual programming around building communities and reducing stress during the pandemic.

Romm is hopeful that COVID will at least change how the health care CEO community invests in and deploys initiatives around social determinants of health. “You have to figure out how to retool your business to incorporate social determinants as opposed figuring how to make social determinants work within your existing business,” he says.

Life science companies, government also tackling COVID-related SDOH

It’s not just payers and providers dealing with COVID-19 related SDOH issues. In the life sciences world, Takeda Pharmaceuticals U.S.A., based in Boston, has worked directly with the cities in which they operate to provide funding and resources on SDOH-related initiatives. They also work number of non-profit organizations, including the Red Cross and National Urban League, to reduce health disparities. Specific to COVID-19, Ramona Sequeira, President of Takeda Pharmaceuticals U.S.A., Inc., also worked to provide emergency supplies and protective equipment to frontline providers.

“Takeda, having been around 200-plus years, we realize that just bringing medicine to market is not going to make us sustainable. It’s doing that and creating an environment where patients can access our medicines,” Sequeira says.

State governments are tackling the issue head on as well. In the Hoosier State, Jennifer Sullivan, MD, Secretary of the Indiana Family and Social Services Administration, says she was tasked with ensuring the response within the state didn’t further the gap that exists for marginalized populations. “We were very aggressive from the beginning in building preventive programs so we wouldn’t have to respond to crises after they occurred,” she says.

An example of this, Sullivan says, is the agency led an initiative to provide temporary housing to the homelessness across the state so they could quarantine and prevent an outbreak in shelters. Those temporary housing sites took direct referrals from local hospitals and local health departments. “Those have been up and running for four months and we have learned so much about the winnable battle that is homelessness in Indiana and COVID was our teacher” she says.

Read more: Indiana’s Jennifer Sullivan on the Hoosier state’s public health turnaround

On the federal government level, the CDC recently released a “COVID-19 Response Health Equity Strategy” framework. This 5-page guide outlines the agency’s priorities, activities and intended outcomes to “broadly address health disparities and inequities related to COVID-19.”

Laura Gottlieb at SIREN says there are frameworks in existence to help health care organizations go down this path, specifically pointing to the National Academies of Sciences, Engineering, and Medicine’s Sept. 2019 report, “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health.” In the months since that report released, in the wake of COVID-19, Gottlieb is optimistic about the increased advocacy she’s seen from health care leaders.

“We’ve seen people step up to talk about the need for data interoperability. We’ve seen people talk about the need for a community health workforce that can really be on the frontlines of social care and medical delivery. We’ve seen people talk about the need for financing structures that can support this kind of integrated care,” Gottlieb says.

About the Author

Gabriel Perna, Senior Manager, Digital Content

Gabriel Perna is the Senior Manager of Digital Content at Health Evolution. He brings 10+ years of experience in covering the intersection of health care and business. Previously, he was at Chief Executive, Physicians Practice and Healthcare Informatics. You can reach him via email at or on Twitter at @GabrielSPerna