Provider Strategies on Community Partnerships and SDOH

The buzzword of social determinants has demonstrated a shift in health care toward a greater focus on the person outside the patient. Health and provider organizations have found that a persons zip code is as much an indicator of health as their genetic code and that social barriers must be addressed to obtain the best outcomes.

Here are some conversations captured at #CCTC on how providers are addressing SDOH and demonstrating measurable ROI through creating successful partnerships, utilizing actionable data, and implementing sustainable health initiatives. For more lineup of speakers visit World Congress website.

Brian Bragg
Vice President, Behavioral Health and Community Integration
Access Community Health Network

Brian is a member of the Access Community Health Network Medical Operations Leadership Team, shepherding a variety of programs focused on men's health, maternal and child health, behavioral health, and infectious disease. His portfolio now includes the development and implementation of initiatives to address the social determinants affecting the health of the patients served by the organization.

Debbie Welle-Powell
Chief Population Health Officer
Essentia Health

In this role, she is responsible for integrating our community health strategy with population health. She works with market leaders, payer partners and community stakeholders to develop community-based population health and risk sharing models that focus on wellness and disease prevention for better health outcomes - with focus given to social determinants and our most vulnerable and needy populations.

Julianna Sellett is the Vice President of Community Health Initiatives for the Carle Health System.

She has over 28 years of health care experience, with special interest in organizational strategy, systems management, performance improvement, population health, as well as cross-sector community integration. Her current work focuses on improving the health, educational achievement, and economic prosperity of disadvantaged populations, with special focus on early childhood development. She is a Registered Nurse (RN) with a Doctoral degree in Nursing Practice (DNP), Master’s degree in Nursing (MSN), and Master’s degree in Business Administration (MBA). She is a Certified Professional in Healthcare Quality (CPHQ) and is Certified in Executive Nursing Practice (CENP).

Advancing Health Equity In The United States

V1: Director of Health and Wellness, Ginny Mantello, MD discusses social determinants of health, health initiatives and polices implemented to advancing health outcomes on Staten Island.


We want to make sure and be mindful that every individual deserves the right to be healthy. Health is a fundamental right and how do we help people regardless of income and race attain their highest level of health. Theres a big push from the city and state departments from the CDC to the borough presidents office. The key is for residents to be engaged but also understanding what in their community is lacking and then reaching out and engaging with  their local governments, also perhaps with the city and state governments, whether it be by phone or social media or in person Ginny Mantello, MD. 


V2: Assistant Commissioner, Bureau of Systems Partnership - Javier Lopez, MPA discusses food policies, strategic partnerships and other initiatives taken by the NYC Department of Health to advance health outcomes in NYC.

We as government have to be technical assistants, thought partners and leaders because we have expertise in areas that our colleagues and neighborhoods may not have the time to invest in. If we're really thinking about long term a lot of the funding and a lot of the work has to reside with the communities and neighborhoods that we serve Javier Lopez MPA.


V3: Deputy Director CUNY Urban Food Policy Institute, Craig Willingham, MPH discussing " The CUNY Urban Food Policy Institute Guide to Food Governance in New York City".


Often times the distribution of certain types of stores and by extensions, certain types of foods really comes down to both the market perception; In the case of supermarkets, supermarket operators or in the case of whole sale distributors those people who go around to have a sense of what they think folks in a given neighborhood would to want to buy Craig Willingham, MPH.

Article Link | Guide to Food Governance in NYC


V4: Brooklyn Borough President Eric L. Adams discussing his role in both advocating and allocating resources to advancing health outcomes in Brooklyn

When you go to some of the health issues and you dig deeper into the report that Dr. Bassett put out, you must really look at the report and separate it from those issues that are beyond our control, theres not much that we can do about and those issues that are not within our control. It doesn't matter who's the borough president, major, or the commissioner of health is; we want to empower people to deal with their health issues. When you do that you begin to empower people to take control, to move away from the old way of thinking. When you look at the major 15 reasons Americans die, 13 of those 15 are clearly preventable; health disease, diabetes, colon cancer, high blood pressure etc. all of those items are preventable.

If we empower people to have lifestyle changes. In the process, they will be ensuring that they have, preventative health care and not so much focus on adequate healthcare, to give them a pill or a needle or injection, or an operation that will treat the symptoms and not the underlining cause. We're not doing that, we're not doing that city wide, we're not doing it and really educating people on how the things they put in their mouths are the things that are causing them to be placed in a hospital at a earlier rate. That is my focus. My focus is to really use my personal victory over diabetes, to turn around, how we think about health care and truly move towards a more proactive health care system Eric L Adams.

 Link: Community Health Profile Report



V5: Bronx Borough President Ruben Diaz Jr. discussing advancing health equity in the Bronx.

About 100,000 more Bronxites are working today than the day that I took office. Last year the crime rate was the lowest since the early 1950's in our borough. 2017 was actually our 5th straight year of under 100 homicides, we're down to 72. I don't really know how you celebrate that, as 1 death is one too many. If you use the national metrics system of 1 homicide per every 100,000 residents, when compared we're safer than Philly, Baltimore, Dallas, Boston, D.C, Chicago.

You don't even have to compare us to Detroit, that was what we used to be 30/40 years ago. Because of that we've seen an increase in our tourism, development, job creation, etc. I give you that overview because there's been a tremendous, body of work done by the elected officials, both present and past. Community leaders, community activist and advocates, non profit organizations, etc. It feels good, and theres a lot to brag about but the one area I cannot brag about is health" Ruben Diaz Jr.


V6: Aletha Maybank, MD, MPH, Deputy Commissioner and Director of The Center for Health Equity, discusses the Health Department’s work to eliminate health inequities in New York City.

I think its a very important to really recognize the role of government, organizations, institutions and policies and how all of that, a lot of times makes it very difficult for folks to fully harness the power that they have, in order to create health that is good in one community such as Brownsville as compared to the financial district. When you have investments that you don't have as control over what are you supposed to do? Thats frustrating for people, they have to worry about their day to day Aletha Maybank, MD, MPH.

Links: One NYC Report | TCNY 2020


V7Melanie Ferris | Research Manager discusses "Community engagement to advance health equity: Strategies and tips".


One of the initiatives that I've been working to evaluate is one thats funded by the Center for Prevention of Blue-cross Minnesota. The initiative is their health equity and prevention initiative. An important and critical part of their work has been community engagement, about half way through the initiative, we asked representatives from each of the agencies to come together and really talk about what community engagement is, how to use it in their work, and to help us put together a list of tips and strategies about authentic community engagement and how that can be used to advance health equity.

The seven key ingredients; 

  1. A focus on relationships

  2. Transparency in goals scope and expectations

  3. Listen to understand 

  4. A goal of fostering community capacity

  5. Activities that bring people together

  6. Strategic partnerships that bring people together

  7. Awareness of organizational capacity

 Link: Strategies & Tips Article 


V8: Sheryl Weir, MPH | Section Manager | Health Disparities Reduction and Minority Health Section | Michigan Department of Health and Human Services. discussing advancing health equity in Michigan.

Unless we understand this broader concept of systems and social determinants, then we will just be putting bandages. For us I think one of the things that is pretty interesting in this department is that three years ago we were Department of Community Health, and there was a Department of Human Services, we rarely interfaced. We were merged about three years ago, and as you can imagine it was pretty major. Department of Community might of been 2300 strong, and Human Services was much bigger and so you're merging two cultures.

I'm really encouraged because what its given us an opportunity to do is to say, well here are multiple determinants that we can impact; human services, services to children, and those kinds of things. Connect those to health services. We can have a bigger impact of addressing social determinants by being one department. We have to work together and I'm so pleased to say theres been some interesting collaborations in this department around issues of racial justice, social justice and how do we use what we have and what we know in our resources together to really try to improve the life experience for our most vulnerable populations Sheryl Weir, MPH.


V:9 Tari Hanneman,MPA | Director of the Health Equality Project at the Human Rights Campaign Foundation discusses advancing health equity for LGBTQ population.


The big difference in rural verses urban is obviously going to be access to care and the number of providers that are available; and then whether or those providers are going to be LGBTQ friendly. If you have a huge menu of providers to choose from you're likely to find some that are going to be LBGTQ friendly, culturally competent and aware, but, if you have a very small slice thats going to be a lot harder. In some places you may only have one hospital in town and it may be a critical access hospital, its the smallest of the hospitals there are and it may not have the capacity to really invest in the best policies and practices around LGBTQ competencies.

In some places there are no providers we work with a lot of youth gender clinics, working with transgender youths and a lot of times we hear of families having to travel hundreds of miles to go to a clinic". In regards to policy "The Equality Act would provide consistent and explicit non discrimination protections for LGBTQ people, across all key areas of life; employment, housing, public spaces, public accommodation services, federally funded programs and jury service Tari Hanneman.


V 10  Noel Brathwaite, PhD, MSPH, Director | Stephanie Slowly, MSW, LCSW-C, Deputy Director | David Mann, MD, PhD, Epidemiologist | Kimberly Hiner, MPH, Program Administrator | Office of Minority Health and Health Disparities, Maryland Department of Health.

The office has a multi part mission. When we look at the mission there are five aspects to our mission. 1. We leverage resources of the department. 2. We also want to provide some guidance to the department relative to policy decision. 3. Strategic initiative influencing the strategic direction of the department. 4. We want to engage in what we call health equity consultation. As well as 5. external communication. Our vision is to really ensure that health across all population groups in Maryland is equal and that people are enjoying their daily life and enjoying wellness in Maryland" Noel Brathwaithe, PHD, MSPH.

From the perspective of how we approach understanding minority health disparities, it comes from the way we look at the data. We can think about four layers, in which we can use data to kind of understand the flow from health to disease within any population. We can track the disparities on all of those four levels. The end point level is essentially, things like death rates and hospitalization rates, the kind of pain, suffering and disability that people experience from having different disease and other bad health outcomes"  David Mann, MD, PhD.

The Diabetes Prevention Program DPP, is a national program provided through the CDC, the state of Maryland has been really champions of this where they've deployed this program throughout the state. We have within our office, the Minority Outreach Technical Assistance program. That is a program where we fund local community based organizations. If you look at the structural level of government, we're the state and most times the state funds the local health departments. What we've decided to do is to bypass the local health department, in this particular initiative, and really fund those community based organizations" Stephanie Slowly, MSW, LCSW-C.

Language and language barriers play a role in health disparities in Maryland. Understanding that Maryland has a very diverse population, we need to meet our clients where they are. In addition to providing medically trained interpreters during medical appointments and translating medical information our office has specially undertaken several projects and initiatives that will work with healthcare providers and those that are working with these communities i.e our MOTA program" Kimberly Hiner, MPH.

Links: MOTA | Health Equity Internship Program | Cultural & Linguistic Competency | Data