00:02
Hello everybody. Thank you for listening to the healthy project podcast. I am your host Corey Dion Lewis. Um, today I have another great guests with me today. Um, talking about something we all understand is super important. You know, where, where you work, live, play and pray, right? All very, very important to the overall health of everybody. Um, but I have somebody super that worked on something really, really

00:29
really cool in my opinion, obviously, you know, you're speaking to the choir here. So when it comes to social determinants and health equity, every that's all great stuff to me. So I'm looking forward to getting your perspective on the social determinants of health, the playbook or the policy you worked on at Dr. Ford with me today. Dr. Ford, thank you so much for being here. I really appreciate it.

00:54
Yeah, so before we get into talking more about the US Playbook to addressing or social determinants of health, can you tell the people a little bit more about yourself and what gets you up in the morning?

01:14
So I am actually a board certified pediatrician by training who has managed to fall into these amazing types of jobs, just sort of speaking up and sharing with different people what I was interested in. And so I went from a long career at Howard University and in the pediatrics department and in the emergency room as a doc. And then I realized I didn't know anything about managed care. So I got an MBA.

01:42
And then that opened up a whole new door of opportunities. And so I, from Howard, I went to Florida where I started my public health career. And what I learned is that, you know, if you're a doc, you have your patients and you may, you know, even if you have a big panel, you still only have that limited amount of influence. But when you work in public health and you do policy, then you can change laws around things. And so I sort of fell in love with that. And so I stayed in Florida for about a year and a half

02:12
And then I moved to Atlanta, where I've been since 2004, in various positions in public health. The district health director for DeKalb and Fulton counties at different times and sometimes together, which is local public health. But I was also Georgia state health officer up until for about a year and a half. And then I went back to local, because you also need to know where you do your best work.

02:42
maybe nine, six, 20, 21. That's so cool. And you know, I was not similarly, but I was always of the thought, you know, I want to, I just want to do as much locally as I can. So we were, I used to do a lot of volunteering, a lot of stuff locally. And it wasn't until I most recently went to the Policy Action Institute through the American Public Health Association.

03:07
where I really understood man policy is how you change the game. Like I knew it, but it wasn't until I, I, it clicked there for me.

03:23
It's tough though, because you know, the beauty of local is that you see the results in a lot of patients and policy, you know, policies sometimes take a while, but you know, we do, you do a food drive or a vaccine drive, you know, you, you say, no, I get that. So, um, I really want to get into the, the U S playbook to address social determinants of health. Can you tell us a little bit about, you know, what was the big

03:49
the beginnings of that, what was the motivation and how did that start?

03:59
So the ideas around social determinants of health literally started right after I finished residency. I worked at a free clinic in East LA. I trained at Children's in Los Angeles and this clinic was Spanish speaking. I spoke so much Spanish that people started complimenting me on my English.

04:23
And so I had a patient, a little girl, who kept coming back week after week with the same ear infection. Now we're at a free clinic, so the medication is free. I speak your language. I didn't hand her mom, you know, elicit instructions. I told her how to take the medication. So these are all the things, you know, we think we're doing correctly. Why is this child coming back time after time with the same ear infection? And so, you know, we want, we're trying to figure out what is going on with her. So I finally just sat the mom down and said,

04:53
here, why is this child keep coming back? Well, they were living in a garage and amoxicillin, which is the most common ear infection medicine has to be refrigerated to be effective. And that was

05:07
such a watershed moment because it was so humbling because here I'm thinking I'm working in a free clinic you know I'm doing I'm doing the best thing for the community and you know I I could have doctored her for years and her ears would not would have gotten worse if anything and so it was a it was a real humbling moment because first of all you know what if I had not asked a question number two

05:33
in her mind she may not have even considered herself unhoused because she had an address you know and so number three is okay well now that I have this information what can I do about it?

05:44
man and that was 20 plus years ago and we're still there we're still there and so I took that experience with me in the White House. The White House is a very busy place and has a lot of competing interests and so I was really trying to figure out where I fit in you know I'm not a I'm not I didn't work on a campaign I wasn't anybody's intern and so you know I'm literally a street public health doc and so I'm trying to figure out where can I make my mark and so

06:14
shared with them, I really think we need to be focusing on the social determinants because what I learned from the pandemic was, you know, the people who were unhoused or were poorly nourished or had all these other non-clinical issues were the ones that did the worst. And so we keep talking about pipeline and training more docs and I think that's wonderful, but just because you pay for someone's medical school education does not necessarily mean they're going to serve in the

06:44
Everybody can't do that work. And so I feel like right now, you know, we're not going to doctor ourselves out of the public health crisis. We're not going to doctor ourselves out of chronic diseases because, you know, a lot of the things that are impacting the chronic diseases are not clinical, you know.

07:00
If you are, you know, if you're living on pepsi, Cheetos and soda, you know, it's pretty hard to treat your diabetes. And we know that, you know, fast food meals are a lot cheaper than, than, you know, a well-balanced diet. So we probably need to start redirecting these sources. And I would love to get your thoughts on this because I feel like there has to be a balance. We talk a lot about, you know, maybe

07:28
not necessarily having more providers, but having more providers that represent the community that they're serving, maybe that would help improve health outcomes. But like you just mentioned, and I do agree that maybe there would be some benefit there, but if we take a patient that has an A1C of 14, and the-

07:54
they don't have any transportation and the closest food sources, the gas station or the food pantry that the local grocery store just drops off all of their pastries at the end of the day at what, what, how are we going to solve that issue?

08:15
Exactly. And so first of all, we're not asking the right questions. You know, your medical assistant in your office may just check off Ms. Brown as a no show.

08:27
She doesn't come, she's not reliable. She doesn't take her medication, you know? But we don't have the time because you've got to see so many patients in a day to make your numbers, you know, to ask the real questions. How come, why is she in no show? Why is she not taking the medication? It may be that she's splitting the medication. I've seen people do this, you know, take half of a dose so they can stretch it out.

08:49
you know, obviously it's not going to work as well. So things like that, but that takes time. You know, it takes time to be, because also if you ask the question, you better have a plan for how to address it. For sure. You know.

09:03
Right. Just ask me something and say, okay, well, thank you. This journey with social determinants of health started with you a long time ago. You have a great story of how that started. Now you're in DC and you're trying to make some moves there. How was the collaboration in getting this thing together? Like, how did it work?

09:27
I see the smile. I don't know if that was like a whoo. It was, what's the story behind that?

09:40
I mean, first of all, you got to think of, here's a person who's brand new. I didn't come from the Obama administration. I'm from Georgia. Everyone's like, who, what, what is she doing? A, B, the first time I started even discussing social determinants of course I started with the health organizations, HHS, and they were like, well, we're doing stuff on that.

10:00
And I was like, okay, but we need to be a little bit more collaborative because it's not just health, it's, it's ed, it's labor, it's all these different agencies. And so, you know, the White House is always doing something. And so you've got opiates, you've got, you know, got maternal and child health, you've got community violence. And so in that setting, when you put together a meeting, if you have like 15 people at your meeting, that's considered a pretty good meeting.

10:25
You know, and so my first meeting with the social determinants of health group, we had 55 people on that call. And so I now I was like, okay, we must be onto something.

10:36
I was also smart enough to get the science folks on board first, or Office of Science and Technology Policy, OSTP. You know, I was looking for an ally. And so they had a huge health equity team I shared with what I was thinking with them. And they were like, we love it, we're on board. And so it was a partnership between Domestic Policy Council and OSTP. And so that gave me a little more gravitas with, you know, some of the other folks. And then once, you know, I told that story at the first meeting about the little girl

11:06
to do this and everybody was like whoa you know.

11:11
And so that the rest is history. We had great attendance at every meeting and people had just such great ideas. And then there was work already being done, but it was done in silos. And so we were trying to figure out how to have a whole of government approach this because the health people were working on it. But I was trying to say, well, we also need, think of education, think of our kids who come to school on a house every day and how that impacts their ability to be successful.

11:37
You know, and so this is an education issue. It's a labor issue because obviously if you don't have good transportation, you can't find a good job. You know, it's a, you know, mental health issue. So there were lots of people that we brought to the table who might not have.

11:52
normally been part of that discussion and they made it much more robust. And because I was a street doc, I wanted to also make sure that I bought external stakeholders who do this stuff every day because I knew that there were communities that were really successful at addressing this. And so what they did was, you know, that was so great. The whole government approach. And I would love for you to, if you could, you know, elaborate more, you know, on the inter-agency collaboration that were instrumental in shaping the playbook.

12:22
bit more about that.

12:30
So my co-chairs were the folks from OSTP, Tweestim was the doc, and she was the first person to say, I got this, I'm with you, I see what you're trying to do, and let's do this. And then the other piece of it, because we knew that data...

12:45
was going to be a huge part of all of this. And so we had to get the data folks, the ONC, the Office of the National Coordinator, who is in charge of all the data standards for the nation. So they had to get on board. And so a lot of it was just literally me reaching out to people saying, hey, this is what I'm trying to do. And then once we started gaining momentum, people started reaching out to me and saying, hey, can I get on your invite list? And then it was kind of like the cool party to come to every week. And so once you get to that level, you're going somewhere.

13:14
So, and it was great. And there were, it was interesting because the National Endowment of the Arts reached out and said, hey, don't forget us. And I thought, oh, okay, well, sure. You know, let's put everybody, you know, Treasury, Department of Treasury, because the Treasury is a...

13:33
responsible for the nonprofit hospitals and hospital community benefits. And so, you know, how do we make sure that community benefits are being used to support social determinants? Well, the Treasury has to be involved and change the rules. And so now the new 990 is, you know, very clear that you can use hospital funds to support social determinants. That is so cool. You know, the playbook is structured around three main pillars, you know, expanding data, gathering and sharing, supporting flexible funding.

14:03
for social needs and supporting backbone organizations. Can you explain the rationale behind these pillars and how they interconnected to address social determinants of health?

14:20
Sure. So I'll tell you, honestly, when I first started thinking about it, I was thinking about categories like nutrition and housing, and I was like, no, it's got to be broader than that. And so we were thinking like, okay, from the highest level, one of the things we need data is key. Because what's happening is that all those agencies are serving the same people. You know, we know that if you are, if you are unhoused, it's highly likely that you're also food insecure, but that's a whole nother agency.

14:47
You know, and so what happens is people have to go from here to here to here to here. I already, you know, we already said there's probably a transportation issue, and now you've got to go to five different agencies, be verified all over again, you know, which is ridiculous. So question one was how do we take the data that agency A already has and share it with agency B so that you don't have to keep going from agency to agency? And so a lot of the discussions were around HIPAA because, you know, docs invoke HIPAA for everything.

15:16
And so one of the things was guidance around like, how do we deal with privacy issues and make sure that, you know, that's protected while we also share this data and how do we share data from agency to agency? It would be like, how do we communicate an Android to an iPhone, you know, because everybody has a different data system. And so how do we find a common communication device so that everybody's using the same thing? So that was number one is the data because we've got to be able to share the information.

15:46
also helps you advocate for what you're doing. Because then you can say, X number of people who are homeless are also food insecure and also have mental health issues and also, you know, et cetera. So it gives you a stronger argument for supporting these things. So the data was key. That's why it's pillar one. Then the...

16:04
Flexible funding comes from my experiences writing grants because grant writing is an art and the funding is very precise usually. It's very prescriptive. You can only use the money for X.

16:18
but people don't live like X. And so there were grants that we had in the past where we would have as a requirement community engagement, but you weren't allowed to feed people. You couldn't use the money for food. So how are you gonna bring somebody into a building at six o'clock at night and not give them something to eat?

16:36
So then you have to have a separate source, somebody else to fund the food or somebody else to support the vouchers for transportation or the childcare or whatever. But if you're really trying to be helpful, you need a funding that is just flexible enough that you can use it for what you need to use it for. So that was number two is how do we change the grant guidance to be a little bit more flexible so that it's, you know, while we maintain reporting structures, we're using it for the right thing. So that was the second pillar.

17:05
And then the final pillar is the support of backbone organizations, because that's the other piece of the grant issue is that, you know, we pay, we find these organizations, we say, okay, we've got a million dollars to address COVID, for example.

17:20
we need you to set up a vaccination site, XYZ. So now they've got to hire people, they've got to get infrastructure together, maybe get a van, that takes time. And so you can't tell them ahead of time, I've got this money. You can only let them know when you get the award in your bank. And so that's a challenge because it takes six months to hire folks. And so that's why grants are always delayed. And so at the end of the grant,

17:50
the nine months, six months before the grant is over, everybody's jumping ship because they know the money's gonna go. And so how do we, in a policy way, support those organizations that really do the work without having to recycle grants all the time? Is there a way, you know, using maybe, I don't know, maybe hospital community benefits, for example, that would have sustainability to support backward organizations in between grants so that, you know, they could keep up the work?

18:20
So there are some, and there's some examples on, in the playbook. Yeah, it's just thinking outside the box a little bit. So, you know, it's exciting. No, absolutely.

18:31
Mm hmm. Data money. Those are the data money people. Data money and the people. Thank you. Yeah, I would love to hear, you know, of any early successes, you know, since you I think you mentioned one, but, you know, since the release of the playbook, had there been any notable early successes or maybe pilot projects that illustrate its impact?

19:05
Well, so when...

19:07
We first started with the playbook. There are state waivers that allow more flexibility with Medicaid and Medicare. They're called 1115 waivers. And there were just a handful of states that were using those waivers to support social determinants of health issues. The last count in March, now there's 26 states that all approved or pending waivers. Outside of the policy,

19:37
I feel like there's a great conversation to have of like, okay, how can I utilize what you did to get people in DC to come together and to support you? And I'm having, I'm having a hard time getting my local community to support, you know, or to come together and create something.

20:07
for maybe some of those smaller community-based organizations or someone just who wants to, like yourself, has had an experience and wants to make a change, what kind of, you know, motivation or support would you say to them or give them advice to start to make some moves or try to navigate through maybe some challenging situations?

20:36
So that's one of the components of the plea book is a whole section that's just tool kits and guidance because it wasn't just enough to put policy out there. It's like, okay, North Carolina is doing XYZ, Rhode Island is doing XYZ. They use this fund and that fund to pull together. So you at least have an idea of where to go or who to reach out to that's already been successful.

21:01
Right. So it wasn't just about putting out like this is what we're doing or what we want to do, but here's some folks that are actually doing it. And basically if you participated in, you know, any of the discussions and your stuff was there, was there any, no, thank you for that. You know, sharing. Was there any, um, what was the kind of the thought or, you know, when this was for the community, was there any thought on how to, um, get community feedback?

21:30
or how was that when developing the playbook?

21:41
Well, we tried to reach out to a lot of the smaller organizations around the nation. You know, once people started hearing about it, they wanted to have a say. You know, I worked in local public health, so there were a lot of contacts there.

21:56
once the word got out that this playbook was sort of in development because what happened, I left the White House in January of 2023 and it was still in draft form. And so by then, you know, we had been talking it up and everybody was like, well, where is it? And the approval process in the White House is pretty extensive and there were so many agencies and everybody had to bless it and make sure that, you know, what they committed to, they would be able to do and, you know,

22:26
policies were added since then had to be included. And so it actually didn't get released until November of last year. And so

22:35
You know, and you know, I felt some type of way about that at first, because I was worried, honestly, that it was going to die when I left because it really, my position was not replaced. And so, you know, who else is going to have that kind of passion to move that type of event forward? But they had a White House fellow, Harrison, who was amazing, Harrison Hines. And he promised me when I was leaving, I will drag this across the finish line. And it's the last thing I do. Michaela Gerwitz, there were some folks there who were really passionate. And so they got it done.

23:05
have ownership of something. It's funny when you see the final, because it's like, this better look like what I left, you know, but when I read it, it was actually better because there was so much new, you know, information, new initiatives that they have put out there. And I was like, y'all, y'all. I mean, it's like, I only imagine this was you saw this as your baby. Like this was your baby.

23:31
Yes, and I always say that. I'm like, this is my baby. And so when I'm looking, I'm like, I better see every line I wrote still in here. And, you know, but they, you know, what are your thoughts on the, on the future of the playback book, like long-term vision.

23:53
So that's the thing. The playbook was initially planned to be a playbook, which then would need to be implemented. Right now we're in the middle of a lot of other crises, most prominently election day. And so right now that's job one.

24:12
And so that's what everyone is focused on right now, is trying to figure out how to keep the momentum going. I think at the local level and state level, there are people working on how are we going to implement some of the things in the playbook. I think that some of the agencies are much more focused now on health equity and how to expand health equity in the work that they do. And so those are things that happen at the federal level, which is really powerful.

24:42
health equity policy and all those federal funding streams, that's a huge one. And that will trickle down into local and state. Yeah, and all of those play a role in improving health outcomes and disparities in people's communities.

25:04
So what needs to happen really to convince people that this is worthwhile? We've got to get some health economists on board to evaluate the financial ROI of this. We know from the social perspective, this is a good thing to do, but.

25:22
I've only seen a few, like literally a handful of articles that are showing the financial benefits of this. If you invest in social determinants, you save money on hospital admissions and you cut down on emergency rooms. This is ROI positive. We need more data like that to make the argument for investing in it.

25:42
Mm-hmm. Yeah. No, I get that 100%. It's not just a woo-woo thing. It actually is a good, smart financial idea. Dr. Ford, do you have any other thoughts or anything you would like to say about the playbook that I didn't bring up today or something you feel like is really, really, people should really understand about this going forward?

26:06
Um, no, I think first of all, just the fact that I'm just really proud of that work. It literally was, uh, my love letter to, to the administration, but also it, it highlights why representation is so important because they took the big chance pulling somebody, you know, out of, out of obscurity more or less to come to, to that level of authority, you know? Um, and they could have, you know,

26:32
picked another campaign person or a policy person that had been around, but I had lived experience in that world and was able to convince them that this was important. And that to me, to have to have the White House put out a statement on the social determinants is a really big deal. And so

26:53
hopefully the work will continue and the financial future will become clearer. I applaud you for even taking that jump to DC because I hear horror stories. Yeah, but it's a necessary evil. You know what I mean? If we don't have representation there,

27:23
then, you know, then what? You know, what can that be like? But we need that. So I can, you know, much respect for fighting that fight.

27:37
Right? Well, it was an honor. I mean, honestly, you know, how many people get to do that? And, you know, I we had conversations, we were still going through COVID. So a lot of the time I was there, we were working from home, and I had not actually been on campus yet.

27:53
And so finally, my supervisor said, why don't you just come to the office? And I was, okay, sure. And I'm driving down Pennsylvania Avenue and I had to pull over. I just burst into tears because the enormity of like, you're about to walk into the seat of democracy, and I thought about my mom and my grandmother and all these people I was carrying with me and even Georgians, because they were like, come and do art due for us. And so it was really powerful and humbling. So I remember I tried to do that.

28:23
I got high calling. Crazy, that would be like, why am I here? So, yeah, I always remind myself. And I had, you know, we park in the ellipse. And so you have to walk around the ellipse, depending on how early you get to a good spot, you don't get a good spot, you may walk far, but you have to go through a gate before you get into the actual.

28:44
you know, campus and I, I would see people walk in there with their sneakers on. And I was like, I cannot walk in. Yeah. I just, I would get to the gate and put my heels on. It's like, I just a matter of respect to just, yeah. So Dr. Ford, thank you so much for being on the healthy project today. I really appreciate it. Um, for those that want to learn more about you connect, um,

29:09
learn more about the playbook, where can they reach out to you?

29:21
So you can reach out at info at BFT consulting. BFT stands for built for tough. BFT consulting.net. That's my email. And I'm certainly on LinkedIn, Sandra Elizabeth Ford. Awesome. So it's pretty easy to track me down. I get a lot of- Awesome. Well, again, thank you so much for being here. Everybody, thank you for listening to the Healthy Project podcast. I'll holler at you next time.