The Aunt Bertha Blog

Selina Sosa

Selina Sosa

Recent Posts by Selina Sosa:

Open Enrollment Now Open!

Open Enrollment for health insurance under the Affordable Care Act has begun.  

Here are 5 things you need to know:

1.  Time is limited!  Open enrollment began on November 1, 2016.  The last day to enroll or switch plans is January 31, 2017.  After January 31, the ability to enroll in insurance is limited to people who qualify for a Special Enrollment Period as a result of experiencing a qualified life event such as losing health coverage, moving, getting married, having a baby, or adopting a child. Unfortunately, illness is not considered a qualified life event, so make sure to enroll on time.

Reentry coordinators take note: Release from incarceration is also considered a life event. However there is only a three month window to get coverage, so it should be addressed soon after release.

2.  Update your application. “It’s important to update your application every year,” says Nora Cadena of Foundation Communities, a nonprofit offering support services to individuals and families in Central Texas.  “Life happens and your life in 2017 will probably be a little different than it was when you enrolled back in 2015.”  

3. Help is available.  Insurance is complicated.  If you need coverage for yourself or someone else, you don’t have to figure it out on your own.  You can avoid the marketplace call center and talk directly with counselors who know your community.  “We live here,” adds Cadena, “so we know the hospitals, the doctors, the networks the prescription costs. We know how things work in Texas and can help you choose the right plan.”  

Foundation Community Photo-2.jpg

4. If you can’t afford insurance, you can still get coverage.  Health insurance is required for everyone. The cost of available plans ranges depending on various factors, including income and family size. Individuals who can't afford the premium still have options.  In addition to financial assistance that can make health insurance more affordable for qualifying individuals, there are other programs that can help in the interim with health care coverage.  

5. You can’t be turned down for a pre-existing condition.  Under the Affordable Care Act, you cannot be turned down for insurance because of a pre-existing condition.

To find an organization in your state that provides assistance with open enrollment and other healthcare options, search  



Stake Your Claim! Help keep program information up-to-date


A key challenge to connecting people with social services is keeping resource information current. Because program offerings and funding change constantly, it is not uncommon to gather a binder full of resource information that becomes outdated after just a few months. "Keeping up-to-date with new resources that can help our clients is definitely difficult," shares Runi Limary, Director of Programs at the Breast Cancer Resource Center in Austin, TX.  "Trying to maintain that data over time is even more challenging because things are constantly changing."

Aunt Bertha works with providers to solve this problem by allowing users to claim and maintain their program listings.  

 Claiming allows organizations to: 

  • Update listing details to ensure accuracy 
  • Indicate resource availability and capacity
  • Attach a screener to make it easier for potential clients to determine their eligibilty and to take the next step to reach out
  • Suggest or remove programs as needed

Providers who claim their programs also get access to a free dashboard that shows the number of times each of their programs has been returned in search results.  This information can be used to support program planning or fundraising efforts.


Anyone who works at an organization can claim programs using their work-affiliated email address.  

Ready to claim?  Click below to find your program and get started...

 Claim my listing!

If you would like support with this process or have questions, email



Five Things to Consider in Your Social Service Coordination Efforts

People in need, as well as those helping them, have traditionally encountered many challenges around finding and connecting to the programs and resources that can help them. For individuals, especially those without easy internet access, it’s difficult to uncover the state and government-funded programs for which they qualify and even more so to discover the myriad of private and charitable resources available.

Case workers, social workers, families, and others in a helping role are presented with another set of challenges including time constraints, unstructured data, incorrect or outdated information, and lack of insight into programs and services available outside of their local areas.

For care teams, a lack of formal processes around identifying patient social needs and follow up also make it nearly impossible to ‘close the loop’ on whether the patient was able to connect and receive help after the referral was made.

To make matters more difficult, not everyone is comfortable offering information about their personal needs and those needs often go undiscovered, undocumented, and excluded from the care plan. Expeditious and personalized social coordination is key to improving many of the metrics health care organizations are tracking for success and is no longer a component of patient care that can be ignored without consequence. 

As people begin working to organize or increase social service coordination within their care settings, here are five areas to consider:

  1. COMMUNICATION. Make sure questions around social needs are part of the process at various stages of the patient journey. People have different comfort levels with different staff members. Don’t leave it to discharge planners alone to uncover outside factors influencing patient health and wellness. In addition, work to improve communication and collaboration among care teams at all points along the care continuum. According to expert Cheri Lattimer, Executive Director for the Case Management Society of America (CMSA) and National Transitions of Care Coalition (NTOCC), integrated care teams that effectively communicate during transitions and throughout the other stages in the patient journey see higher staff and patient engagement, as well as, an overall improvement in health outcomes. 
  2. ALWAYS INCLUDE CASE MANAGERS/SOCIAL WORKERS. Keep case management and social service teams in the loop at all times. Their function is an integral part of a patient-centered care plan.
  3. STANDARDIZE. Set up a uniform way to manage social coordination within the organization and work to get everyone ‘on the same page’. It will enhance efficiencies and make it easier to track progress. Providing standardized tools and processes will also help care teams eliminate information silos and function more cohesively when addressing patient needs that fall outside of the medical spectrum.
  4. EMPOWER. Empower everyone (including the patient and those helping him) to get involved in creating a good outcome. One way is by providing an easy way for everyone to find and connect with the programs and services that can help them stay well. Since patient needs outnumber staff resources, facilitating patient involvement is a good way to distribute the case load. Most people want to help themselves and are willing to take the proper steps if pointed in the right direction. 
  5. Analyze the data and monitor trends. Uncovering service gaps can provide insight and drive smarter decisions within the organization. Efficient and timely social coordination improves health outcomes, as well, as patient satisfaction. 
Social factors impacting patient health is no longer a topic of discussion solely reserved for discharge planners coordinating transitions. It’s in the best interest of everyone involved in the patient’s journey to be informed and empowered to help when necessary.
Topics: Social Services access to social services care coordination

Is Social Service Coordination included in your Treatment Plans?

It’s been well documented that social factors play a significant role in people’s health.  In fact, studies show that up to 40% of a person’s overall health outcome can be attributed to things like food stability, transportation, housing, and employment.  



It’s becoming increasingly clear to providers that achieving the triple aim of better patient care, improved health outcomes and lower costs, will require more focus and better coordination around patient needs that fall outside of the healthcare setting.  New payer models are contributing to the rapid acceleration toward more patient-centered care but many are asking, is enough emphasis being placed on social determinants impacting people’s health?

Under the Affordable Care Act's Hospital Readmissions Reduction Program, hospitals are fined significant penalties for repeated admissions that are deemed preventable.  The reality is that multiple readmissions are not always due to of a lack of quality care but rather social factors that are not controllable by hospitals and are not taken into consideration in penalty calculations.  Consider the diabetic who doesn’t have access to healthier foods, lacks adequate transportation to follow up appointments, or is forced to choose between basic needs; healthier food or medication?  Medication or rent?

Health care organizations that implement a standardized process for social service coordination and make it a consistent part of the patient journey will not only create direct economic benefits, it will positively affect patient engagement and satisfaction, as well.  In addition, creating a standardized process of addressing social factors hindering patient wellness allows providers to better track and report trends which ultimately leads to better business decisions.     

Aurora Sinai Medical Center in Milwaukee went a step further in their efforts to address outside social factors impacting patient health by placing social workers in the ER department full time.  They realized that among their patient population, the highest utilizers of emergency room services were constantly in crisis.  They weren’t thinking about scheduling appointments and planning ahead but rather where they were going to sleep or whether they could get groceries. Over a monitored period of time, the social workers began helping patients schedule appointments to see a doctor and coordinated services such as transportation and child care services for the appointment. The results were measurable. Visits by the selected targeted group to the Aurora Sinai emergency room fell by 68 percent, from 487 to 155. Compared to four months before the program was implemented, costs fell from $1.5 million to $440,000. (Kodjak 2015). 

Equipping healthcare staff with the tools and processes to facilitate social service coordination is a win-win-win for both patients and providers, as well as, health care plans covering the costs.  It’s also a great step in shift toward patient-centered care.    

Topics: social determinants of health health care patient care