Addressing Social Determinants of Health in Minnesota

Priorities and Strategies Among Health Plans, DHS, and Medicaid IHPs

Stratis Health has a long history of addressing health disparities and improving health equity in Minnesota. To advance that work in today’s environment, we set out to identify and understand current priorities and strategies for addressing social determinants of health (SDOH) among Minnesota of health plans and state public programs. Stratis Health sent a brief snapshot survey of SDOH priorities and strategies to nine health plans based in Minnesota, as well as to the Minnesota Department of Human Services (DHS) public programs. All nine health plans responded, as did DHS. In addition, Stratis Health also reviewed the current SDOH priorities for the 28 individual Minnesota Medicaid Integrated Health Partnerships (IHPs).

SDOH Survey Results: Health Plans and DHS

Overall Priority for Addressing SDOH

Seven of the ten responses indicated addressing SDOH is their first or second top priority. Three indicated addressing SDOH was lower but still among their top five priorities, competing with COVID-19 and financial and economic concerns for time and attention.

Specific SDOH Focus Areas

Two specific SDOH focus areas emerged as the consistent priorities across respondents – Mental Health and Food Insecurities. Two areas emerged as second-tier priorities – Housing Instability and Substance Use Disorder. Interestingly, Transportation Problems was identified by six respondents as an ongoing challenge yet did not rise to a top priority for any of them.
The SDOH risk factors not currently priority areas for respondents include education, employment, financial strain, interpersonal safety, physical activity, and disabilities. Many of these are more difficult for the health plans to act on directly, so it is not surprising that they did not emerge as priorities.

Strategies for Addressing SDOH

There are six strategies for addressing SDOH most implemented by Minnesota health plans and DHS:

  • Identifying and/or using internal or external data sources to determine next steps (9 respondents)
  • Strengthening partnerships with community-based organizations (9 respondents)
  • Hiring or utilizing Community Health Workers (CHWs) to address SDOH (8 respondents)
    • Including a subset which is implementing or considering implementation of Pathways Community CHW HUBs (4 respondents)
  • Supporting providers in implementing/utilizing screening tools to identify SDOH risk areas and needs (8 respondents)
  • Supporting providers in implementing or using an e-referral platform (e.g., NOWPOW, Aunt Bertha, Healthify, Unite Us) (7 respondents)
  • Utilizing community health needs assessments to prioritize and plan SDOH interventions (6 respondents)

Innovative or Unique SDOH Strategies

Respondents shared in survey comments some innovative strategies being implemented which were not among the survey response options:

  • Developing and utilizing HIE to gather and compile member SDOH and connect the member with SDOH resources
  • Reducing readmissions for the homeless by offering hospitalized homeless members case management services to address SDOH and health concerns
  • Utilizing Community Care Connectors to refer members to resources available to them locally or regionally
  • Partnering with MDH Health Care Homes program on addressing SDOH

Medicaid Integrated Health Partnerships’ (IHPs) SDOH Priorities

The Minnesota Department of Human Services recently issued a report about the efforts by the IHPs to address SDOH. Relevant results from that report are highlighted here. The 28 Medicaid IHPs’ priorities and work underway in addressing SDOH generally align with health plan priorities and efforts.

Specific SDOH Focus Areas

Top priorities are Mental Health, Substance Abuse Disorder, Family and Community Support, Food Insecurities, and Housing Instability.

Strategies for Addressing SDOH

The top areas of work are:

  • Facilitating referrals to CBOs (22 IHPs)
  • Partnering with CBOs (12 IHPs)
  • Sharing community resource lists (6 IHPs)

Innovative or Unique SDOH Strategies used by IHPs:

Screening for Social Determinants of Health and Track Populations

  • Screening for social risk factors or mental health conditions
  • Providing regular follow-up to patients in the target population
  • Tracking and monitoring patients with social needs
  • Using population health tool linked to EHR to identify eligible patients, track participants, share information, connect them to services, and “close the loop” to ensure uptake of services

Strengthen Community Partnerships and Resource Accessibility

  • Developing and sharing community resource list
  • Facilitating referral/enrollment in the community or onsite resources and programs
  • Tailoring resource lists, care plans, other services to specific patients based on needs
  • Using care coordinator/patient navigator/CHW to connect patients to resources

Conclusions

Based on the information gathered and reviews, Stratis Health offers several key findings:

  • Addressing social determinants of health is a high priority for Minnesota-based health plans, DHS public programs, and Minnesota’s Medicaid IHPs, and in many instances, SDOH is the top priority.
  • There is a consistency of SDOH focus areas across health plans and alignment between health plans, DHS, and the IHPs, especially in Mental Health, Food Insecurities, and Housing Instability.
  • Many of the key SDOH intervention strategies are similar across health plans, DHS public programs, and IHPs. Strategies include:
    • Hiring or utilizing Community Health Workers to address SDOH.
    • Identifying and/or using internal or external data sources
    • Strengthening partnerships with community-based organizations
    • Supporting providers in implementing and utilizing screening tools to identify SDOH risk areas and needs

Stratis Health will continue to collaborate with a wide variety of partners, including health plans, DHS, and IHPs to address health disparities and inequities, drawing upon these findings to inform and guide efforts. Our online learning and resource center Culture Care Connection supports health care providers, staff, and administrators in their ongoing efforts to provide culturally competent care, including assessing and addressing implicit bias.