HHS SDOH Policy Activity

The U.S. Department of Health and Human Services (HHS) has indicated their support of federal, state, and local level efforts and policies to address social determinants of health and social need through initiatives and activities among a number of agencies. Below we briefly outline the federal agencies NASDOH identified which are working on specific social determinants of health activities or initiatives.

NASDOH will continue to track and update the list overtime. Please check back quarterly for updates.

You can find more information about NASDOH’s policy activity and federal COVID-19 funding and flexibilities for SDOH-related programs.

White House U.S. Playbook to Address SDOH

The White House released a U.S. Playbook to Address SDOH. The playbook provides resources and guidance for incorporating SDOH considerations into everyday practice and proposes solutions to addressing SDOH from a policy perspective. The playbook also describes recent efforts across multiple federal agencies to consider SDOH and work towards addressing the adverse health outcomes they cause.

In conjunction with the Playbook, CMS released a framework describing coverage of health-related social needs (HRSN) under Medicaid and CHIP. The document provides guidance for how HRSN services may be covered under Medicaid and CHIP. It further clarifies the differences between SDOH and HRSN for coverage determination.

Office of the Secretary

Office of Environmental Justice (OEF)

HHS established a new office in summer 2022 that is tasked with integrating environmental justice into the HHS mission to improve health in disadvantaged communities and vulnerable populations across the nation. The new Office of Environmental Justice (OEJ) was created through President Biden’s January 2021 Executive Order Tackling the Climate Crisis at Home and Abroad which directed agencies to make achieving environmental justice part of its mission by developing programs, policies, and activities that address environmental impacts on disadvantaged communities. The OEJ will be led by Acting Director Sharunda Buchanan, who previously worked at CDC overseeing multiple environmental health-focused offices and divisions.

Social Impact Partnership to Pay for Results Act (SIPPRA)

Signed into law on February 9, 2018, the Social Impact Partnership to Pay for Results Act (SIPPRA) would fund social programs that achieve real results and redirect funds from ineffective programs to programs with demonstratable results. $100 million in funding is now available for proven models integrating social services and medical services care and must include a state or local partner in its model. This amount will be made available until 2028 (10 years). In addition, the OS-HHS is participating on the Federal Interagency Council on Social Impact Partnerships that is tasked with determining the disposition of the funds. The Commission on Social Impact Partnerships, a private-sector advisory panel, has also been appointed. On February 22nd, 2019, the Notice of Funding Availability was published that invites applications from State and local governments for awards under SIPPRA. On March 28th, 2019, the Commission on Social Impact Partnerships convened for a public meeting (meeting minutes available here).

Deputy Secretary

Quality Summit

On July 9, 2019, the Department of Health and Human Services (HHS) announced the formation of the Quality Summit (QS) to convene key industry stakeholders and government leaders to discuss how current quality programs administered by HHS can be better evaluated, adapted, and streamlined to deliver value-based care focused on improving health outcomes for Americans. The Executive Order signed by President Trump on June 24, 2019 directs federal agencies to develop a Health Quality Roadmap that aims to align and improve reporting on data and quality measures across federal health programs.


Assistant Secretary for Health

Healthy People 2030

The Healthy People 2030 framework includes language around “social health,” “eliminating health disparities,” and “social, physical, and economic environments.” One of the overarching goals for 2030 includes: “Create social, physical, and economic environments that promote attaining full potential for health and well-being for all.”

National Academy of Medicine (NAM) Convening

Of particular interest to the agency is how SDOH can support the Department of Health and Human Services’ (HHS) value-based work. The Office of Disease Prevention and Health Promotion partnered with the National Academy of Medicine (NAM) on a workshop “Reducing Health Care Spending Through Interventions that Address Non-Medical Health-Related Social Needs” in Washington D.C. on April 26th, 2019.  The workshop focused on a wide range of issues related to the social determinants of health including current and potential CMS and private payer reimbursement policies, the role of population-wide policy change, and the latest research on the return on investment (ROI) and value proposition for such work.

Office of the Surgeon General

Call to Action: “Community Health and Prosperity” RFI

The Surgeon General is writing a report on the connection between community health and prosperity, business investment in local community health, investment strategies, the role of a healthy workforce in business success, and contributions of local policy makers toward community development. In an effort to better inform this report, the OSG and Center for Disease Control and Prevention released a Request for Information RFI on September 6, 2018 soliciting view, recommendations, & data on the connection between community health & prosperity (see NASDOH’s November 2018 comment letter here).

Surgeon General Report

The Office of the Surgeon General published the Community Health and Economic Prosperity (CHEP) Report in early 2021. The report focuses on engaging businesses as stewards and stakeholders to improve the health of Americans and help foster a more sustainable and equitable prosperity. Karen DeSalvo and former Utah Governor and HHS Secretary Michael Leavitt contributed to the report; they focused on the value of collaborations with public health departments to achieve business and community health goals. Other NASDOH members were involved in developing and reviewing the report, and promoting it. See the CHEP here.

SDOH Return on Investment (ROI)

The Surgeon General has indicated interest in better understanding the evidence available for specific social determinants of health interventions that may deliver a consistent return on investment (ROI). In response, NASDOH provided the Surgeon General with a letter in 2019 identifying several organizations and their social determinants of health activities (see letter here).

Assistant Secretary for Planning and Evaluation

Report: Expanding the Evidence Base for SDOH

In September, 2021 the Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report on expanding the evidence base regarding social determinants of health (SDOH). RAND helped ASPE evaluate current evidence from the programs and policies focused on SDOH and helped determine the SDOH research questions, data sources, and data gaps that could guide development of a research agenda centered on SDOH. RAND’s review offered important insight but gaps in understanding of SDOH interventions remain. ASPE noted that, to gather more evidence, investments are needed in addition to an HHS-driven SDOH research agenda.

Toolkit: Early Childhood Braiding Funding

ASPE announced the release of the “Early Childhood Braiding Toolkit,” which is a toolkit intended to assist states and local communities in braiding, blending, or layering multiple federal funding streams (for example, Head Start and the Child Care and Development Fund) to increase the supply of quality early care and education programs and improve access to comprehensive early childhood and family support services. This September, 2021 toolkit aims to help stakeholders better understand the process of braiding multiples sources of funding and how to find existing resources that can help with the process.

Report: Disparities in COVID-19 Vaccination Rates Across Racial and Ethnic Minority Groups in the United States

HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a May, 2021 issue brief titled, “Disparities in COVID-19 Vaccination Rates Across Racial and Ethnic Minority Groups in the United States”. As of March 3, 2021, 38 states and the District of Columbia reported race or ethnicity for individuals who have received at least one dose of the COVID-19 vaccine. Although nearly half of vaccinations have unknown race or ethnicity in national data, data completeness for states in this brief ranges from 67% to 99%. Among those reporting states, Black and Hispanic populations have consistently received a lower share of the vaccine by population compared to White populations.

Report: COVID-19 and Economic Opportunity: Unequal Effects on Economic Need and Program Response

The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) published a report that discusses the trends in poverty, food insecurity, housing, and early childhood education during the COVID-19 pandemic (2021). The report found that communities of color continue to experience higher rates of poverty than white Americans, and ASPE estimated that 13.6 percent of Americans were in poverty at the end of 2020, compared to an annual poverty rate of 10.5 percent in 2019.

Report: Social Determinants of Health Data Sharing at the Community Level

The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report entitled “Social Determinants of Health Data Sharing at the Community Level,” which includes a review of community-level efforts to address the social determinants of health (SDOH). The report identified enabling factors or facilitators, challenges and opportunities related to community-level initiatives.

Report: Social Determinants of Health Data Sharing at the Community Level

ASPE published a report (2021) reviewing community-level efforts to address the social determinants of health (SDOH) and developed a cross-sectional analysis of three community-level efforts. The report identified enabling factors or facilitators, challenges and opportunities related to community-level initiatives.

Issue Brief: Facilitating Local Cross-Sector Collaboration: Strategies for Intermediaries

The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) published an issue brief describing health disparities related to the COVID-19 pandemic (2021). The report found that COVID-19 highlighted health disparities in infection, death, and vaccination rates among Black, Hispanic, Native American, and Native Hawaiian/Pacific Islander populations. The report recommended short-term steps to address these disparities and long-term solutions to address socioeconomic drivers of health outcomes, and strengthen public health infrastructure.

Reports to Congress: Social Risk and Medicare’s Value-Based Purchasing Programs

Section 2(d) of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act called for a study evaluating the effect of individuals’ socioeconomic status (SES) on quality measures and measures of resource use under the Medicare program. ASPE published its second required report in June of 2020, which examines the effect of individuals’ social risk factors on quality measures, resource use, and other measures under the Medicare program (available here). ASPE published its first mandated report in December 2016 (available here).

Housing Options: Literature Review

In June 2019, ASPE’s Office of Disability, Aging and Long-Term Care Policy released a report, “Housing Options for Recovery For Individuals With Opioid Use Disorder: A Literature Review” that identifies gaps in the literature on housing models to support recovery from opioid use disorder (OUD) in individuals who experience homelessness or housing instability.

Office of Inspector General

RFI Regarding the Anti-Kickback Statute

The Office of Inspector General (OIG) requested for information from the public on how to address any regulatory provisions that may act as barriers to coordinated care in an attempt to accelerate transformation to a value-based system that included care coordination. The OIG is also reviewing Stark Act Safe Harbors, where appropriate, among social services and health care providers (e.g., providing a patient “something of value”, like transportation vouchers or food bank coupons).

Office of the Chief Technology Officer

Roundtable on Data and SDOH

The Office of the Chief Technology Officer hosted a roundtable event on October 3rd, 2019 that focused on how to use data related to social determinants of health to improve health outcomes. The roundtable included discussion on how to catalyze the use of SDOH data at the federal, state, local, and individual levels to improve health outcomes. Participants, in addition to Karen DeSalvo, included the chief data officer (Mona Siddiqui), former U.S. Chief Technology Officer (Aneesh Chopra), President of Center for Open Data Enterprise (CODE) (Joel Gurin), and HHS Assistant Secretary for Health (Brett Giroir). (Roundtable summary available here).

CDO Report

The HHS Chief Data Officer (CDO) is interested in better understanding how data and information that exists within various agencies can be successfully shared between and among all agencies to better utilize the data and increase data transparency. They are seeking feedback and recommendations on an HHS report titled, “The State of Data Sharing at the U.S. Department of Health and Human Services” that will be released on September 18, 2019. In addition, the agency is developing Action Steps and plan to convene numerous Federal agencies in the first quarter of 2019 to discuss data sharing (see NASDOH’s March 4th letter to the CDO that highlights several use cases and associated case studies on current activities and efforts here).

Center for Medicare

CMS Health Equity Action Plan

In May 2022 CMS released an action plan designed to advance health equity and challenge industry leaders to address systemic inequities. This action plan builds on the Administration’s push to provide affordable quality health care and drive health equity across HHS. To advance health equity, all CMS Centers and Offices will work with and share best practices across states, health care facilities, providers, insurance companies, pharmaceutical companies, people with lived experience, researchers, and other key stakeholders. In Summer 2022, CMS will convene these stakeholders to align with the Biden-Harris Administration’s long-term strategy for advancing health equity and seek ways to improve maternal health outcomes.

Proposed Rule: Changes to MA and Medicare Part D Plans for CY 2023

CMS released a proposed rule in January, 2022 that would make changes to Medicare Advantage (MA) and Medicare Part D plans for calendar year (CY) 2023. Notable to NASDOH, the proposed rule includes a provision on social determinants of health and special needs plans (SNPs). CMS proposes to require all SNPs to include one or more standardized questions on the topics of housing stability, food security, and access to transportation as part of their health risk assessments (HRAs). The wording of individual questions would be specified in sub-regulatory guidance. Data from these standardized questions would be available to CMS for collection and analysis, though the timeline for this is not specified in the current proposal. CMS is soliciting comments on when these standardized questions should be implemented with 2024 as the earliest contract year under consideration.

Special Enrollment Period (SEP) Extension for Marketplace Coverage

In March 2021, the Centers for Medicare & Medicaid Services (CMS) announced it will extend access to the Special Enrollment Period for healthcare.gov until August 15, 2021. The extension gives Americans additional time to enroll or re-evaluate their coverage needs. On average, savings accrued from American Rescue Plan tax credits are expected to decrease premiums by $50 per person per month and $85 per policy per month.

Medicare Advantage (MA) Part C & Part D Flexibility Final Rule

On April 5, 2019, CMS issued a final rule that updates the MA or Part C and Medicare Prescription Drug Benefit (Part D) programs through promoting innovative plan designs, improved quality, and choices for patients. Additional flexibilities include MA plans ability to offer “additional telehealth benefits,” increased integration of Medicare and Medicaid benefits and appeals and grievance processes for MA Dual Eligible Special Needs Plans (D-SNPs), and a process to allow Part D plan sponsors to request standards extracts of Medicare Parts A and B claims data regarding enrollees.

2020 Medicare Advantage (MA) Final Call Letter

In response to the comments on the Part I and Part II Advance Notices, the 2020 Medicare Advantage (MA) Final Call Letter was published on April 1, 2019. The Final Call letter includes a number of changes, including the new category of supplemental benefits that may be offered by MA plans – Special Supplemental Benefits for the Chronically Ill (SSBCI). This includes supplemental benefits that are not primarily health related and aims to better enable MA plans to tailor benefit offerings, address gaps in care, and improve health outcomes for the chronically ill population.

2020 Advance Notice & Draft Call Letter

On January 30, 2019, CMS released Part II of the 2020 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies (the Advance Notice), and Draft Call Letter. CMS accepted comments on all proposals in Part I and Part II through March 1, 2019 before publishing the final Rate Announcement and Call Letter on April 1, 2019. Beginning in CY2020, MA plans can offer non-primarily health related supplemental benefits to chronically ill enrollees. The 2020 Call Letter provides guidance about these new special supplemental benefits for the chronically ill, including the definition of a chronic condition and how to submit these benefits in the MA bid (see NASDOH’s comment letter here).

Medicare Advantage (MA) Part C Proposed Rule

On October 26, 2018, CMS issued a proposed rule that would eliminate barriers for private MA plans to cover additional telehealth benefits. This includes providing MA plans more flexibility to offer government-funded telehealth benefits, greater ability for MA enrollees to receive telehealth from places like their home, and greater flexibility for plans to offer clinically-appropriate telehealth benefits otherwise not available to Medicare beneficiaries.

2019 Medicare Advantage (MA) Call Letters

On April 2, 2018, CMS expanded the definition of “primarily health related” services. As a result of this reinterpretation, plans now have the flexibility to support patients with SDOH interventions that benefit their health, including transportation support and certain home improvements. In coming plan years, at home remote monitoring & food support may be available. On April 27, 2018, CMS submitted a memo that offers a reinterpretation of the “uniformity requirement” that clarifies non-discrimination for disadvantaged groups.


On March 6, 2018, CMS announced the MyHealthEData initiative to empower patients by giving them control of their health care data. Patients can use their data to seek out providers and services that meet their unique needs as well as better understand their overall health needs, prevent disease, and make more informed decisions about their health care. The department has expressed interest in a similar effort to connect patients to additional data, including data beyond primarily “health care data” to include SDOH-related data.

Center for Medicaid

CMS Guidance: Home- and Community-Based Services

The Centers for Medicare & Medicaid Services (CMS) issued guidance in May, 2021 for American Rescue Plan Act (ARPA) funds that will be used for Medicaid beneficiaries’ home- and community-based services. The agency indicated that the guidance will help states improve health equity for Medicaid beneficiaries and allow them to seek assistance in the living situation of their choice. Notably, the guidance references multi-sector collaboratives and addressing SDOH as ways to support HCBS COVID-related activities. The full letter detailing the guidance may be seen here.

CMS Guidance to States: Address SDOH in Medicaid and CHIP

On January 07, the Centers for Medicare & Medicaid Services (CMS) issued guidance to state health officials designed to drive the adoption of strategies that address the social determinants of health (SDOH) in Medicaid and the Children’s Health Insurance Program (CHIP).It describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH. The guidance letter is available here.

CMS Working Group

CMS has established a working group on core measure review, where one of the core measures they are considering involves the social determinants of health. The group is headed by the Director of the Division of Quality and Health Outcomes and reports to the Deputy Director of the Center for Medicaid and CHIP Services. CMS, commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible.  The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers.

North Carolina Waiver

On October 19, 2018, CMS approved North Carolina’s Section 1115 waiver that includes an innovative new pilot program focused on addressing the SDOH for high-risk, high-cost beneficiaries. The waiver allows four regional pilots that assemble a network of health care providers, community-based organizations, and social service agencies that contract with managed care plans to provide services to enrollees. The particular service areas included in the pilot are housing, food, transportation, and interpersonal violence/toxic stress. In addition to the CMCS interest areas mentioned above, CMCS has heard from states who have an interest in emulating some of what North Carolina has done with their waiver, as well as advancing their own concepts. CMCS would like to provide more guidance for those states and their MCOs.

State Medicaid Director Letters

CMS released a memo on January 11, 2018 that sets forth waiver options for states pursuing SDOH interventions. These could include behavioral health, mental health, opioids focused, or work-related interventions. CMS noted the broad range of social, economic, and behavioral factors that influence or impact an individual’s health and wellness and the growing body of evidence that suggest targeting certain health determinants may improve health outcomes. In particular, CMS noted productive work and community engagement as an area that has the potential to improve health outcomes.

State Governor Letter

On March 14, 2017, former HHS Secretary Price and CMS Administrator Seema Verma sent a letter to the nation’s governors indicating their intent to work with states to improve their Medicaid programs. They indicated several key areas where they will work to collaborate with states, including improvement of the State Plan Amendment approval process, support innovative approaches to increase employment and community engagement using 1115 waivers, and provide a reasonable process to comply with the Home and Community-Based Services rule.


Comment on HHS Report: Innovative State Initiatives and Strategies for Providing Housing-Related Services and Supports under a State Medicaid Program

MACPAC sent a letter to congressional leaders and Acting HHS Secretary Norris Cochran describes describing how Medicaid can be used to address social factors that affect the health of beneficiaries, and encourages CMS to issue guidance on providing housing and community based services to individuals with substance use disorders (SUD) and mental illness (2021). The letter was in response to a recent HHS report, “Innovative State Initiatives and Strategies for Providing Housing-Related Services and Supports under a State Medicaid Program to Individuals with Substance Use Disorders (SUD) Who Are Experiencing or at Risk of Experiencing Homelessness.”

Annotated Bibliography: Racial and Ethnic Disparities in Medicaid

MACPAC released “Racial and Ethnic Disparities in Medicaid: An Annotated Bibliography,” reviewing studies on disparities in Medicaid that have appeared in peer-reviewed journals as well as those published by policy and research organizations and government agencies (2021). The studies document that Medicaid beneficiaries who are Black, Hispanic, and American Indian and Alaska Native experience poorer outcomes and experience more barriers to care than white beneficiaries.

Center for Medicare and Medicaid Innovation (CMMI)

White Paper: Vision for CMS Innovation Center

CMS released a November, 2021 white paper detailing the vision for the CMS Innovation Center over the next 10 years, titled “Driving Health System Transformation – A Strategy for the CMS Innovation Center’s Second Decade.” CMS leaders also participated in a webinar where they discussed accountable care, advancing health equity, support for innovation, affordability, and partnerships to achieve system transformation. The goal of the strategy is to achieve equitable outcomes through high-quality, affordable, person-centered care, carried out through five strategic objectives: Drive Accountable Care, Advance Health Equity, Support Innovation, Address Affordability, and Partner to Achieve System Transformation.

Guide: Using the Accountable Health Communities Health-Related Social Needs Screening Tool

CMS released its Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool, which describes the Accountable Health Communities (AHC) Model’s tool to help identify “adverse social conditions that negatively impact a person’s health or health care.” These adverse social conditions are distinct from the social determinants of health, as they are more individualized than structural. The document states that better screening for these adverse social conditions can help improve individual patient outcomes while lowering overall medical costs.

Direct Contracting RFI

CMS announced Direct Contracting (DC) that aims to improve quality of care and health outcomes, reduce Medicare expenditures through the alignment of financial incentives, and focus on patient choice and care delivery for beneficiaries, including complex, chronic, and seriously ill populations. DC includes three payment model options. CMMI announced an RFI in May 2019 on one DC model – the Geographic Population-Based Payment (PBP) model. This model would allow entities to assume total cost of care (TCOC) risk for Medicare FFS beneficiaries in a defined target region. In particular, the model aims to address beneficiary needs related to social determinants of health (such as food, housing, and transportation) with particular attention to whether the geographic scale contemplated under the payment model option creates new opportunities for success in terms of community-based initiatives. Comments were due by May 23rd (see NASDOH’s comments here).

Maternal Opioid Misuse (MOM) model

On October 23, 2018, CMMI announced the Maternal Opioid Misuse (MOM) model to combat the country’s opioid crisis. Specifically, the model addresses fragmentation in the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). The model aims to improve the quality of care and reduce costs for mothers and infants. CMS plans to execute up to twelve cooperative agreements with states, whose Medicaid programs will implement the model with one or more care delivery partners in their communities. A maximum of %64.5 million will be available for state awardees over the five-year model period. The Notice of Funding Opportunity ended on May 6, 2019.

The Integrated Care for Kids (InCK) model

On August 23, 2018, CMMI announced the Integrated for Kids (InCK) model – a model focused on local service delivery and state payment model aimed at reducing expenditures & improving quality of care for children covered by Medicaid or CHIP. The model incorporates prevention, early identification, and treatment of priority health concerns including behavioral health and physical health care utilization. CMS plans to award funding for up to eight cooperative agreements at a maximum of $16 million each in December 2019 to implement the seven-year model beginning January 1, 2020.

Accountable Health Communities (AHC)

On September 8, 2016, CMMI announced the Accountable Health Communities (AHC) model that addresses the gap between critical care and community services through testing whether systematically identifying and addressing health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Currently, 30 organizations are participating in the AHC model and the participant performance began in May 2017 and is anticipated to end on April 30, 2022.

Health Resources and Services Administration (HRSA)

HRSA Funding Awards

HHS announced $1 billion in May, 2021 to fund construction and renovation projects at community health centers across the nation. The $1 billion from the American Rescue Plan will go towards roughly 1,400 health centers funded by the HRSA Health Center Program and can be used for COVID-19 related capital needs and to construct new facilities, renovate and expand existing facilities, and purchase new equipment.

In April 2021, HRSA announced more than $12.7 million in funding to 61 public, private and non-profit entities across 35 states to serve rural communities and address rural health disparities as part of its community-based Rural Health Care Services Outreach Program (Outreach Program). Services will focus on social determinants of health, chronic disease management and prevention, care coordination, telehealth, dental care, and behavioral health, among other areas. In addition, for the first time, funds will go toward supporting the Healthy Rural Hometown Initiative (HRHI) to address underlying factors that drive rural health disparities.

Annual Report to the Secretary of HHS and Congress

In December 2016, the Health Resources and Services Administration and the Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) released “Addressing the Social Determinants of Health: The Role of Health Professions Education” (link). The report details the need to advance education in SDOH for all health care professionals/students and outlines four recommendations for HRSA:

  • Support interprofessional clinical educational activities to address the SDOH needs for vulnerable populations using the Title VII, Section 747 and 748 funding mechanisms.
  • Support for programs to assess the impact and effectiveness of various methods of training learners regarding SDOH in the funding opportunity announcements for grant applications.
  • Support for faculty development in funding opportunity announcements for Section 747 and 748 grant applications.
  • Encourage the Secretary of HHS to support Medicare’s continued development of a payment infrastructure based on value, in particular, one that supports team-based care to facilitate improved outcomes through attention to the

Centers for Disease Control and Prevention

Notice of Funding: Closing the Gap with Social Determinants of Health Accelerator Plans

The CDC released the grant DP21-2111 – Closing the Gap with Social Determinants of Health Accelerator Plans. The DP21-2111 grant will fund approximately 20 state, local, tribal or territorial jurisdictions to develop an implementation-ready social determinants of health (SDOH) accelerator plan. Recipients will convene and coordinate a Leadership Team consisting of multisectoral partners to plan and develop an SDOH accelerator plan to fast-track improvements in health and social outcomes related to chronic health conditions among population groups experiencing health disparities and inequity. At least one territory and one tribe will be funded. To ensure geographic diversity, no more than three state and local applicants per HHS region will receive awards. The approximate average award amount is $125,00 with a budget period of 12 months. Grant applications will be open until July 5.

Director’s Statement: Racism is a Serious Public Health Threat

The Centers for Disease Control and Prevention (CDC) Director Rochelle P. Walensky declared racism a “serious public health threat,” in a statement issued on  April 8, 2021. In her statement, Dr. Walensky reviewed the CDC’s plans to address racism as a driver of racial and ethnic health inequities and study the impact of SDOH on health outcomes. Walensky emphasized that racism includes the “structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they worship and gather in community.” The CDC also announced its new web portal “Racism and Health”, a catalyst for education and scientific discourse around racism and health.

Extension: Eviction Moratorium

The Centers for Disease Control and Prevention (CDC) extended its eviction moratorium until June 30, 2021. The CDC cited research showing that the eviction moratorium has led to an estimated 50% decrease in eviction filings; however, there have still been more than 100,000 eviction filings since September.

Pilot Project: Reduce Chronic Disease by Advancing Health Equity

The Centers for Disease Control and Prevention (CDC) awarded $7 million over two years to the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) to fund a pilot project that will seek to advance health equity by addressing SDOH. The project will engage high-need communities that have made a difference in the SDOH through local programs and policies, with support from multi-sector partnerships. This pilot project will focus on five areas linked to chronic disease: built environment, community-clinical linkage, food insecurity, social connectedness, and tobacco-free policy.

CDC and ASTHO Stakeholder Convening on Collaborations to Address Social Needs

On March 6-7, 2019, the CDC and the Association of State and Territorial Health Officials (ASTHO) hosted a convening to share knowledge, strengthen relationships, and explore collaborations between participants and community integrators to address health-related social needs.

Health Impact in 5 Years

The Health Impact in 5 Years (HI-5) initiative aims to achieve lasting impact on health outcomes within communities through interventions that address the conditions in the places where we live, learn, work, and play. HI-5 focuses on non-clinical, community-wide approaches that have evidence reporting health impacts, results within five years, and cost effectiveness or cost savings.

Agency for Healthcare Research and Quality

Online Data Visualization Tool on SDOH Data Related to Poverty and Access to Internet

The Agency for Healthcare Research and Quality (AHRQ) updated its online data visualization tool on SDOH data specifically related to poverty and access to internet, which is essential for obtaining home-based telemedicine and important for basic healthcare access. The resource includes a map which shows county-level percentages of households with computers and smartphones and percentages of households with any type of broadband (including cellular data plans). The map also shows county-level percentages of individuals in poverty.

Phase One: Visualization Resources of Community-Level SDOH Challenge

AHRQ asked participants to develop an app that addresses the need for increased use of standardized patient-reported outcomes data in clinical care and research in an effort to bring the voice of the patient into care delivery and wellness processes.

Phase Two: Visualization Resources of Community-Level SDOH Challenge

On March 7, 2019, the Agency for Healthcare Research and Quality (AHRQ) announced a “challenge competition” in which participants develop new online tools to present and encourage the use of free, publicly available SDOH data to better understand and foresee communities’ unmet health care needs. These visualization tools must utilize information from at least 3 or more free, publicly available data sources and must be developed and presented so AHRQ can apply them in at least 2 of the following ways:

  1. To develop data linkage, machine learning and modeling studies
  2. To understand how consumers seek and make health care decisions
  3. To evaluate community health status
  4. To predict needs for emergency, hospital, and community health care services

The challenge includes two phases: In phase 1, participants submit concept abstracts and prototype designs of data visualization methods (due June 7, 2019). In phase 2, semifinalists will develop proofs-of-concept. Phase 1 winners are expected to be announced in July 2019 and begin phase 2.

Administration for Children and Families (ACF)

Low-Income Household Water Assistance Program (LIHWAP)

HHS, through the Administration for Children and Families (ACF), announced the launch of the Low-Income Household Water Assistance Program (LIHWAP), which will expand access to more affordable water and help low-income households affected by the COVID-19 pandemic pay their water and wastewater bills, avoid shutoffs, and support household water system reconnections related to non-payment. About $166.6 million, or 15 percent of allocated LIHWAP funding, is being made immediately available to LIHWAP grantees to support the establishment of the program. In total, $1.1 billion will be available through LIHWAP grants, including $500 million in American Rescue Plan funding. ACF is enabling states, territories, and tribes to set program rules that are reasonable for their communities and begin launching the program as soon as possible.

Administration for Community Living (ACL)

National Summit on Health Care and Social Service Integration  

The Administration for Community Living (ACL) hosted a National Summit on Health Care and Social Service Integration on March 4, 2020. The Summit brought together leaders from key sectors within health care industry to discuss the integration of medical and social care to improve the health care outcomes among vulnerable populations. During the Summit, successful partnership models were highlighted, and participants discussed enablers and barriers to replicating and scaling these models across the country. Additionally, financing of social care, use of interoperable technology platforms, and the roles of state and federal government were addressed.

See the event agenda and a related paper on Community Integrated Health Networks: An Organizing Model Connecting Health Care & Social Services.

White House Office of National Science and Technology Council (NSTC) and White House Office of Science and Technology Policy (OSTP)

White House OSTP RFI On Digital Technologies

The White House Office of Science and Technology Policy (OSTP) issued a Request for Information (RFI) on Digital Technologies for Community Health. OSTP requests input about how digital health technologies are used, or could be used in the future, to transform community health, individual wellness, and health equity. The deadline to respond to the RFI is February 28. NASDOH will submit a response, which will include members’ examples and insights from on the ground

National Science and Technology Council (NSTC) Emerging Technologies Report

In March 2019, the National Science and Technology Council (NSTC) released a report highlighting various emerging technologies that can assist older adults in aging successfully and providing recommendations to improve the quality of life and reduce the financial and emotional burden of care to aging individuals and their families, among other topics. Recently, the NSCT released a follow-up report highlighting ongoing and anticipated work intended to support older adults across the country, particularly amid the COVID-19 public health emergency.

Office of Minority Health (OMH)

Virtual Symposium

On Thursday, September 17, the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) hosted a virtual symposium to discuss state, tribal, territorial, and community-based efforts to address COVID-19 among racial and ethnic minority and American Indian and Alaska Native populations. On the symposium website, OMH provides tools and resources on data, testing, vaccines, and clinical trials to support efforts to address COVID-19 among racial and ethnic minority and American Indian and Alaska Native populations.

Office of the National Coordinator for Health Information Technology (ONC)

United States Core Data for Interoperability Version 2 (USCDI v2)

ONC released the United States Core Data for Interoperability version 2 (USCDI v2), a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. The July, 2021 update gives a clearer direction toward the standardized, electronic exchange of social determinants of health (SDOH), sexual orientation, and gender identity (SO/GI) among several other updated data elements, laying the foundation for the provider community to start systemizing the capture and use of SDOH and SO/GI data in the clinical setting. While encouraged, this update does not require health professionals, such as doctors and nurses, to record this data or individuals to share it.

360X Project

ONC released an August, 2021 update to the 360X project. The 360X project was launched to utilize health IT interoperability to define implementation guidance for enabling more efficient and safer patient transitions of care. The ONC stated that transitions of care for patients, such as from a nursing home to an emergency department, place patients and health care providers in a dangerous position due to the COVID-19 pandemic. As a result, ONC is partnering with the private sector to develop unique and rapid transitions of care to ease challenges and increase safety for both patients and providers.

The Office of the National Coordinator for Health Information Technology (ONC) announced a funding opportunity, Strengthening the Technical Advancement and Readiness of Public Health via Health Information Exchange Program (STAR HIE Program). This initiative aims to advance HIE services to benefit public health. The program’s 2 main objectives are: building innovative HIE services that benefit public health agencies, and improving the HIE services available to support communities disproportionately impacted by the COVID-19 pandemic. The award will allocate $2,500,000 to fund up to five (5) awards with a period of performance of up to two (2) years in the form of cooperative agreements.

National Institutes of Health (NIH)

Improve Access to Testing Among Underserved and Vulnerable Populations

In early October, the National Institutes of Health (NIH) awarded nearly $234 million to improve access to testing among underserved and vulnerable populations. The funding will support established screening and community partnerships at 32 U.S. institutions, focusing on African Americans, American Indians/Alaskan Natives, Latinos/Latinas and Native Hawaiians, and older adults, pregnant women, and people who are incarcerated or experiencing homelessness. The underserved population testing initiative has plans to award additional funding if the resources are available.