RVA Community Cares Helps Richmond-Area Residents Address Social Determinants of Health

June 5, 2020

As the COVID-19 pandemic stretches across the United States, many wonder what the effects of this virus will have on the health and financial well-being of Americans. In 2019, the Federal Reserve reported one in four Americans could not afford a $400 emergency[1], meanwhile nearly 400,000 Virginians filed for weekly unemployment benefits as of May 31, which has been an ongoing issue since mid-March when the pandemic closed businesses and forced layoffs. The economic crisis caused by COVID-19 raises concerns about how individuals and families will access resources for their most basic needs, such as food, transportation, and a safe place to live, and ultimately how this will impact the social determinates of health (SDOH), defined by the Centers for Disease Control and Prevention (CDC) as the “conditions in the places where people live, learn, work and play.” Left unmet, these social needs can impact one’s health and how often an individual will access the health care system.

Health Quality Innovators (HQI) is helping individuals meet their SDOH needs through RVA Community Cares, an Accountable Health Community (AHC) funded by the Center for Medicare and Medicaid Innovation (CMMI). The program screens area Medicare and Medicaid beneficiaries in clinical settings for five core needs (food access, transportation, living situation, utilities and personal safety) and connects them to community services and resources. High-risk beneficiaries (those who have visited the emergency department two or more times in the past 12 months) are assigned a Navigator. The beneficiary and Navigator work together to develop a personalized action plan to assist with accessing resources and resolving their needs, then the Navigator follows up with the beneficiary regularly for 12 months. As COVID-19 rapidly changes how we administer health care, the RVA Community Cares team now conducts screenings remotely to maintain social distancing and because social needs are not going away during the pandemic. For some beneficiaries, the current situation has created new needs due to recent unemployment while others, who were experiencing hardship before the crisis, have had their needs exacerbated.

Since many community service providers might have altered their hours and means of communication, or entirely shut down during the COVID-19 crisis, RVA Community Cares has been reaching out to verify that services are still available before referring beneficiaries. The team stays up to date on policy changes and the impacts on beneficiaries as well. HQI Navigator Cherie Warfield recently reported hearing confusion from one Richmond city parent regarding where to pick up her child’s lunches provided by the school system. Her son normally eats both breakfast and lunch at school and the family could not afford to miss these provided meals. Cherie was able to provide the beneficiary with the most updated information, so she was still able to obtain food for her child while he was out of school.

Early data has shown that low-income Americans will be disproportionately affected by this pandemic due to poorer health outcomes and less access to resources than their wealthier counterparts.[2] While utility payments and evictions have been suspended for the time being to alleviate the financial strain caused by this pandemic, many individuals will eventually find themselves with overwhelming payments and potential evictions in the future.

During an interview on April 8, 2020 with NBC’s Today Show, Dr. Deborah Birx, White House Coronavirus Response Coordinator, discussed the impact of COVID-19 on Americans living with preexisting conditions. When asked why African-Americans appear to be impacted at a higher rate, Dr. Birx was quick to point out the importance of addressing social determinants, stating, “This brings us back to the social determinants of health, and I think once this is over we really need to look very carefully into each of those items to really look at what it’s going to take to ensure the health of all Americans.”

RVA Community Cares, along with other community stakeholders and health systems, are working hard to ensure beneficiaries have access to the most up-to-date and useful resources and organizations to help them navigate through this crisis.

For more information on how RVA Community Cares is helping Medicaid and Medicare beneficiaries in the Richmond area, please feel free to visit our web page.

The project described was supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

Disclaimers: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The research presented here was conducted by the awardee. Findings may not be consistent with or confirmed by the findings of the independent evaluation contractor.




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