What You Should Know:

– Socially Determined, the leading social risk analytics company, and Uber Health, the healthcare platform for seamless benefit coordination, have announced a partnership to empower individuals and families facing common healthcare challenges.

– The strategic joint effort focuses on connecting vulnerable Medicaid, Medicare Advantage, and commercially insured beneficiaries with critical supplemental benefits like transportation, food delivery, and medication delivery.

Targeting the True Drivers of Health

It’s no secret that health is influenced by more than just medical interventions. Social determinants of health (SDOH), like food insecurity, transportation barriers, and lack of social support, play a significant role in well-being. Socially Determined’s expertise in identifying and analyzing these SDOHs, combined with Uber Health’s comprehensive platform for delivering supplemental benefits, creates a powerful solution for addressing these challenges head-on.

Targeted Support for Improved Outcomes

This partnership goes beyond simply providing access to resources. By leveraging Socially Determined’s sophisticated social risk data and analytics, healthcare organizations using Uber Health’s platform can now:

– Precisely identify individuals with the greatest needs: Utilizing real-time data on social determinants of health like food insecurity, transportation barriers, and lack of social support, they can pinpoint those who would benefit most from targeted interventions.

– Align available benefits with eligible members: With access to patient benefit data, healthcare providers can confidently match patients with the appropriate resources covered by their insurance, ensuring effective utilization of existing benefit structures.

– Empower engagement and address daily challenges: By removing the everyday hurdles of transportation, food access, and medication availability, patients and families are empowered to focus on their health and engage more effectively with their healthcare journey.

– Enhance access to healthcare and food resources: This partnership extends the reach of healthcare beyond the clinic walls, ensuring communities have equitable access to vital resources that contribute to overall well-being.

– Improve health and healthcare outcomes: Ultimately, this collaborative effort aims to break down barriers to care, leading to better health outcomes, reduced healthcare costs, and a more empowered healthcare experience for vulnerable populations.

“For years, our payer and provider customers have utilized our social risk analytics to better understand and address the challenges their members and patients faced every day. And now we’ve developed purpose-built analytic models designed explicitly for Uber Health’s key benefits that immediately help identify those individuals with the greatest need for each benefit,” said Trenor Williams, Co-Founder and CEO at Socially Determined. “Once our payer and provider partners know who needs assistance and what specific challenges need to be addressed, they require a partner to help mitigate those risks and eliminate those barriers. Uber Health’s knowledge, approach and ubiquitous network provides the perfect partner for our analytics and allows our customers to drive measurable, improved outcomes and member experience.”

Hospitals, health systems and group practices nationwide are finding value and effectiveness by partnering with an outsourced care guidance resource to extend clinical staff and strengthen care management support. The addition of a structured and highly scalable care guidance program that goes beyond mere navigation efforts provides a unique solution as a service proposition to comprehensively address many of the operational and financial challenges that directly affect the entire provider ecosystem. 

An Extension of the Clinical Team Beyond Mere Patient Navigation

Modern care guidance is an evolution of patient navigation that combines a systematized assessment to support disease-specific clinical conditions with a tech-enabled, human-led solution. Care guidance serves as an extension of a hospital’s clinical team to support a range of service lines and support activities. 

When properly designed and implemented, care guidance supports a myriad of clinical and non-clinical functions, including facilitating pre-and-post-discharge and continuation of care. While care coordination usually includes a limited set of commonly performed tasks like scheduling follow-up appointments, helping patients understand what the next step in their clinical journey should be, care guidance goes deeper into social determinants and the life factors that can impact a patient’s ability to stay on track. 

An effective care guidance program depends on specially selected care guides who work to establish a peer-to-patient connection with patients and their families. This human-led approach builds trust, enhances a patient’s ability to communicate and helps to uncover issues that pose barriers to care. The support of care guides then works to resolve these issues and assist patients in the ongoing process of their care. However, while the human touch is vital, care guides are unlikely to meet efficiency goals without a technology platform that goes beyond logging into structured workflows and barrier resolution pathways.

As healthcare organizations experience the profound financial impact of nurse shortages, care guidance is providing an innovative and efficient solution. It provides truly effective supplementary support services, functioning as a lower-cost extension of clinical teams and freeing up labor, time and resources so that nurses can focus on high-value clinical tasks.

A successful care guidance program delivers a strong return on investment (ROI) by improving efficiencies, reducing time and resource allocation, and helping overutilized clinical care teams focus on truly clinical items, all while improving patient satisfaction and retention Care guidance is of especially high value in alleviating non-clinical tasks and of its ability to help identify and solve barriers embedded in the social determinants of health that have an outsized impact on the patient care continuum. When a guidance program is properly deployed, it functions to promptly identify and resolve non-clinical issues patients experience before they become clinically problematic and costly. 

Value of a Technology-Enabled Care Guidance Resources 

A technology-enabled care guidance resource offers the most effective patient activation solution. It seamlessly integrates with a health system’s care management team to reduce clinical resource use, improve patient experience, advance health equity and enhance value-based care and reimbursement.

The right mix and integration of human and tech elements support personalized and meaningful peer-to-patient relationships and personalized communication, providing patients and their families with the connected support they need to stay on track and engage in the management of their condition throughout their care continuum. 

Integrating care guidance with information technology can significantly enhance the efficiency and effectiveness of healthcare services. By leveraging these technologies, care guidance programs become more agile, patient-centered and efficient. They facilitate quicker responses to patient needs, streamline administrative tasks and ultimately improve the overall patient experience within the healthcare system.

Collaborative Function of Care Guidance

Collaboration between provider teams supports a triad of care coordination and management. Hospitals and their clinical staff receive the extended support they need from a dedicated care guidance service.

• Reach and manage more patients, maintain their continuity of care.
• Remove non-clinical tasks from the workloads of nurses and clinical staff.
• Perform follow-ups and monitoring, conducting follow-up tasks and ensuring that potential issues and barriers are proactively identified and resolved.
• Schedule appointments, screenings, preventive care and annual wellness visits.
• Find financial resources, such as assistance programs, to alleviate medical costs.
• Arrange transportation and other logistics that enable a patient’s ability to receive care.
• Ensure compliance, adherence and medication management. 
• Reduce unnecessary service utilization and avoidable readmissions.

Addressing Social Determinants of Health and Resolving Barriers to Care

As healthcare organizations prioritize to deliver equitable, patient-centric care they must consider the full spectrum of a patient’s condition, including non-clinical factors and socioeconomic characteristics that influence their ability to access, receive and adhere to care.

Care guidance takes into account the role of social determinants of health (SDoH), with personalized services provided by skilled and trained care guides that recognize these non-clinical factors that influence an individual’s ability to access care and adhere to treatment. It’s this “human touch” that supports patients who are at-risk based upon SDoH characteristics.  These patients frequently require amplified levels of activation and monitoring that cannot be addressed within the typical hospital’s resource capacity and clinical scope limitations. 

SDoH are categorized by socioeconomic, education, cultural and environmental domains. Sub-standard conditions among these domains are shown to perpetuate patient health disparities, contribute to their unmet resources, services and transportation needs and widen health inequities, especially affecting those with chronic health conditions.

When non-clinical factors, which account for 80% of patient issues, are not promptly addressed and effectively resolved, they can lead to:

• Health deteriorations
• Excessive rates of clinical service utilization
• Extended hospitalizations and readmissions
• Higher total cost of care

Care guidance programs have proven to be effective in supporting disadvantaged and underserved patient populations who are at-risk for these complex health challenges. 

Data Captures Provide Strategic Insights

Optimally, care guides are equipped with scalable, technology platforms that provide structured workflows and use evidence-based disease and condition-specific protocols to proactively identify and resolve practical and non-clinical barriers experienced during the care journey. A patient activation platform that augments a hospital’s care management workflow and automates protocols helps uncover both non-clinical and clinical issues and barriers. With this technological support, care guides ensure that non-clinical issues get promptly resolved and clinical issues are immediately escalated to proper clinical care teams. 

An effective care guidance platform captures SDoH data and disparity-related barrier resolution, exceeding the capabilities of typical electronic health record (EHR) systems which are not specifically designed to facilitate the kind of resolution workflows that are needed to address health equity and SDoH issues. A specialized platform facilitates operational improvement by seamlessly exchanging relevant insights for each patient population. 

How Information Technology is Utilized in Care Guidance:

• Resource Allocation: Data analytics help healthcare organizations allocate resources effectively based on patient needs, optimizing the patient navigation process.

• Machine Learning and AI: AI algorithms analyze patient data to offer personalized recommendations for treatments, lifestyle changes and support services.

• Interoperability: IT systems communicate across different platforms ensuring the smooth flow of patient information between healthcare providers and navigators, improving coordination of care.

• Data Analytics: By analyzing patient data, IT systems predict potential health issues, allowing providers to intervene early and prevent complications.

• Measuring Outcomes: Collect data to measure the effectiveness of their services, including patient satisfaction, adherence to treatment plans and health outcomes.

• Continuous Improvement: Based on collected data, patient navigation programs can be improved to better serve patients’ needs.

Data analytics within the platform provide insight into non-clinical issues, identify probable SDoH risks and facilitate personalized communication. AI and machine learning anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication. Led by this intelligence, care guides provide patients with the information they need to engage in the process of their care and empower each consumer to receive a better understanding of their treatment plan and options. 

Why More Health Systems Are Considering Care Guidance Programs 

Care guidance is now becoming a “must-have” addition to the service line portfolio of health systems, hospitals and provider organizations. It is at the nexus of managed care priorities where care guidance represents an innovative approach to connected care, advancing heath equity and delivering high-quality care.

A well-designed, scalable care guidance program offers a cost-effective, connected care solution, aligning with the “Triple Aim” goals of improving care, enhancing population health and reducing costs. Patients receive personalized, equitable care, clinical staff can focus on their core tasks and hospital administrators can improve financial and operational performance. This is where care guidance presents the most value and opportunity.

About Craig Parker, JD, CPA

Craig Parker, JD, CPA, CEO, Guideway Care, a company that partners with healthcare organizations to deliver on the promise of health equity through its unique combination of highly trained Care Guides and its patient activation platform. Craig Parker has a history of building innovative healthcare companies with business models that improve care delivery and provide better experiences for all involved. Before taking the helm at Guideway Care, Craig served as a senior leader in healthcare companies working in the patient experience and provider efficiency spaces. In his role as CEO, Craig serves as the company’s chief evangelist, spreading the message that Guideway Care’s services improve life for patients and providers alike.

What You Should Know:

• Pair Team, a virtual and community-based primary care solution connecting Medicaid’s highest-risk patients to high-quality care, today announced its expansion into seven new California markets: Fresno, Merced, Monterey, Los Angeles, Santa Cruz, San Joaquin, and Stanislaus counties.
• This move enables the company to further improve access to California Advancing and Innovating Medi-Cal (CalAIM) care benefits by reaching a larger number of patients, providers and community health partners.

Pair Team Expansion to Improve Accessibility to Healthcare by Reaching a Larger Demographic

CalAIM represents a lasting commitment from The California Department of Health Care Services (DHCS) to overhaul the state’s Medicaid health care program, Medi-Cal, making it more fair, organized, and centered around individuals. Despite the positive impact of the initiative on enhancing care accessibility, primary care providers (PCPs) and community-based organizations (CBOs) face challenges participating in the new care model due to insufficient funding and essential resources.

In response to these challenges, Pair Team has focused on seven new markets, addressing their specific needs for increased access to CalAIM programs. For instance, Los Angeles County, with its 2.7 million Medi-Cal members, includes some of the most high-needs individuals across the nation. Moreover, Central Valley counties in California consistently grapple with systemic access issues for Medi-Cal beneficiaries, especially concerning the availability of primary care physicians.

Pair Team actively breaks down barriers to care by collaborating with local clinics, shelters, food pantries, and other CBOs. Through a comprehensive artificial intelligence-driven platform, the team delivers services such as virtual urgent care, medication management, grocery delivery, and housing navigation, catering to the complex needs of their patients. Acting as an extension of safety-net organizations, Pair Team provides a multi-disciplinary care team comprising community health workers, behavioral health specialists, and nurses. Empowering their partners with essential tools, Pair Team facilitates increased access to high-quality care for a broader range of patients.

“Over 13 million Californians — one in three — rely on Medi-Cal for their health care coverage. However, many face barriers in receiving care including lack of transportation, housing and mobile phone access,” said Neil Batlivala, CEO and co-founder of Pair Team. “Health care is a basic right for every American and shouldn’t be more difficult to access for any one person. It’s our mission to bridge the care access gap, and this expansion enables us to do so for more Californians. We’re excited to continue bringing care to those who need it most alongside our innovative partners in these communities.”

Understanding the multifaceted dimensions of patient wellness goes beyond the medical symptoms presented in a clinical setting. In order to maximize positive patient outcomes, healthcare providers must examine and monitor the social factors and life circumstances, or the Social Determinants of Health (SDOH), that significantly influence population health. These determinants – encompassing aspects of life such as access to care and technology, food or housing insecurity, core demographics and more – play a pivotal role in shaping the health trajectories of individuals and communities alike. 

Monitoring social determinants of health can have a profound impact on healthcare outcomes, but there are challenges faced by healthcare providers in leveraging this data. Understanding SDOH creates promising pathways toward a more informed, equitable, and effective healthcare ecosystem.

The Importance of Monitoring SDOH Data

Enhanced awareness of a patient’s background and social environment has the potential to elevate patient engagement and experience, significantly improve patient care and lead to more positive outcomes. A recent survey shed light on an encouraging trend – as many as 80% of American hospitals are now collecting data on SDOH. This growing recognition of SDOH’s importance reflects a positive shift towards a more holistic approach to healthcare. However, the survey also unearthed a concerning disparity: only 53% of these hospitals are collecting the data regularly.

This gap underscores a compelling opportunity for healthcare providers to further harness the potential of SDOH data for improving patient care. The structured collection and analysis of SDOH data is needed to achieve a more informed approach to healthcare and to unlock the transformative potential of SDOH insight through powerful use cases including:

• Enhancing Patient Engagement and Experience: Gaining a holistic understanding of a patient’s social circumstances by collecting, monitoring, and analyzing SDOH data fosters a more empathetic and personalized approach to patient experience. It enables providers to engage with patients in a meaningful way, aligning care plans with the individual’s unique life circumstances. Furthermore, when patients perceive that their healthcare providers understand and respect their social circumstances, trust may be strengthened. This trust is foundational for effective communication and adherence to care plans, thereby enhancing the overall patient experience.
  
• Improving Patient Care and Outcomes: Awareness of SDOH can inform the development of tailored care that considers not just the medical, but also the social and lifestyle needs of patients. This nuanced approach facilitates personalized care, better adherence to care plans and improved health outcomes. Additionally, a robust understanding of SDOH helps healthcare providers become better positioned to educate patients about the impact social factors can have on their health and empower them to take proactive steps toward improved health outcomes. Beyond individual care, awareness of SDOH supports broader community health initiatives. It provides a lens through which healthcare providers can identify and address systemic issues affecting community health, thereby contributing to the overall well-being of the populations they serve.
  
• Program and Solution Innovation: SDOH data can be instrumental in informing health policy and program development, ensuring that policies, programs and solutions are designed to address the most pressing social factors impacting health. The integration of innovative technological solutions such as machine learning, predictive analytics and people-based data can further augment the analysis and utilization of SDOH data, driving more informed decision-making, better patient care and the creation of the next innovative solution.

The rich insight that SDOH data provides is indispensable in bridging the healthcare gap between providers and the communities they serve. As healthcare evolves towards a more patient-centric model, the importance of nurturing a deep awareness of the SDOH among healthcare providers cannot be overstated. This awareness is not merely a conduit for enhanced patient engagement and improved care but a basis for advancing health equity in a progressively interconnected world.

Challenges in SDOH Data Utilization

The road to regular SDOH data collection is fraught with challenges as limited resources pose a significant barrier, especially for smaller or underfunded healthcare facilities. The requisite technology, personnel training and the process alterations necessary for regular data collection and analysis demand a level of investment that may be prohibitive for some. 

Furthermore, the rising tide of patient mistrust adds a layer of complexity to this endeavor. Patients may be wary of sharing personal information pertaining to their living conditions, financial status or other social factors unless there is a clear understanding of how this data will be used to enhance their care. The “creepy factor” often associated with extensive personal data collection further exacerbates this mistrust, potentially hindering the efforts towards regular SDOH data collection.

However, there are a few ways healthcare providers and their partners can overcome the challenges that come with consistently monitoring social determinants of health:

• Collaboration and Partnership: Forming partnerships with tech firms, data companies, community organizations and other healthcare providers can pool resources and expertise to overcome resource limitations. Joint initiatives such as partnering with an SDOH data provider or the development of shared platforms for SDOH data collection and analysis can reduce the individual resource burden on healthcare providers.
• Standardized Frameworks: The lack of a standardized approach to collecting, analyzing and utilizing SDOH data is a significant hurdle. Without a coherent framework, the efforts of healthcare providers may remain siloed, thereby diminishing the potential impact of the collected data on patient care and outcomes. Developing standardized frameworks for SDOH data collection, analysis and utilization can drive consistency, collective utility, and quality in SDOH data practices.
• Training and Capacity Building: Investing in training healthcare personnel on the importance of SDOH, ethical data practices and effective data utilization techniques can significantly enhance the effectiveness of SDOH data utilization efforts. Harnessing the power of technology to automate data collection, analysis and integration can significantly mitigate the resource constraints faced by healthcare providers.

Taking Action

The healthcare landscape is in a state of constant evolution, with the potential to profoundly impact lives on both an individual and community level. Central to this evolution is the recognition, integration and continuous use of Social Determinants of Health (SDOH) data in the delivery of healthcare.

As healthcare providers and stakeholders continue to delve deeper into the realm of SDOH, the ripple effects are bound to extend beyond the confines of healthcare facilities into shaping policies, engaging communities and improving individual health outcomes. The potential to enhance patient care, improve community health outcomes and cultivate a more equitable healthcare landscape is within reach, hinging on our collective resolve to embrace and effectively utilize SDOH data.

And now is the time to act.

• For Healthcare Providers: Embrace continuous learning, foster inclusivity and engage in collaborative initiatives to share insights on SDOH data utilization.
• For Policymakers: Champion supportive policies and encourage dialogue with healthcare stakeholders to understand the practical implications of SDOH data.
• For Technology and Data Firms: Innovate ethically and advocate for seamless data integration in healthcare.
• For the Community: Stay informed, engage with local healthcare providers and support advocacy efforts towards health equity.

Monitoring and leveraging Social Determinants of Health (SDOH) data is pivotal in the pursuit of a more holistic, patient-centered approach to healthcare, which is essential for improving individual and community health outcomes. By understanding and addressing the social and environmental factors that significantly impact health, healthcare providers can tailor patient care and experiences, optimize resources and contribute towards a more equitable and inclusive healthcare system.

About Christine Lee
Christine Lee is Head of Health Partnerships for predictive data innovator, AnalyticsIQ. Christine has over a decade of experience in the data and analytics space and has worked with industry leaders across verticals like healthcare, pharma, non-profits, and more.

What You Should Know:

• Pair Team, a virtual and community-based primary care solution connecting Medicaid’s highest-risk patients to high-quality care, today announced it has raised $9 million in Series A funding. The financing was led by NEXT VENTURES, with participation from PTX Capital, Kapor Capital, Kleiner Perkins, Y Combinator, and several notable healthcare angel investors including Jay Desai.
• The funding will be used to help Pair Team accelerate its expansion across California by enabling the company to grow its network of safety net organizations and scale its current team to support additional patients.

Funding to Accelerate Expansion of Large-Scale Safety Net Organisations 

With nearly $10B in total funding, California Advancing and Innovating Medi-Cal (CalAIM) is integrating social support services such as housing, food access and transportation through local health plans for low-income residents. The goal is to elevate the role of community-based organizations (CBOs) such as shelters, food pantries, and rehab facilities in the care delivery system. This is the future of Medicaid laid out by CMS, and other states like New York are following suit. However, local clinics and CBOs lack the resources to effectively coordinate and establish a new model of care.

Pair Team solves these issues by partnering with local health centers and community-based organizations, giving them access to a shared, value-based care management platform that is utilized by Pair Team’s network of safety net organizations and providing staffing support to fill gaps in care access and coordination. By enabling existing organizations to provide both virtual and in-person care through its shared platform, Pair Team connects Medicaid’s highest-risk patients with the information and services they need, such as housing coordination, grocery delivery, medication management, virtual therapy and other primary care services.

“Pair Team’s hands-on approach is changing lives for thousands of Californians who are not able to access the care needed to better their health. Our virtual and community-based solution builds personal and meaningful relationships with our patients to help them regain trust in and access to the health care system,” said Neil Batlivala, CEO and co-founder of Pair Team. “This latest financing will help us bring whole-person care to more patients across California, and soon nationally. This is Medicaid’s regulatory moment, and we are here to help catalyze much-needed change for the wellbeing of our most vulnerable communities.”

What You Should Know: 

– Ounce, a company bridging the gap between health and housing has raised a $5.2M seed round co-led by Meridian Street Capital and Flare Capital Partners with participation from Chelsea Clinton’s Metrodora Ventures Wilshire Lane Capital, Chris Nassetta (Hilton CEO), Taylor Justice (Unite Us cofounder), and others.

– Ounce Community Health Workers (CHW) currently serve more than 2,000 D.C. residents, helping them enroll in Medicaid, apply for energy assistance, schedule PCP and pediatrician appointments, avoid eviction, and connect with community resources for transportation and nutritious food, among many other services. 

Building Bridges Between Housing and Health

Today, more than 300,000 D.C. residents are enrolled in Medicaid and approximately 27,000 low-income D.C. households face housing hardship. Making matters worse, as of June 21 this year, Medicaid redeterminations have resulted in 3,000 D.C. residents losing access to critical health coverage. Access to health insurance and a safe and affordable place to call home is fundamental to many areas of life, including school performance, job retention, physical and mental health, and economic security. Medicaid managed care organizations (MCOs) are committed to improving health outcomes for this population, but struggle to engage them due to factors such as invalid or frequently changing contact information, lack of trust in the healthcare system, limited access to transportation, low health literacy, and inadequate childcare support. 

To address these issues, Ounce embeds its team of trained Community Health Workers (CHWs) within affordable housing properties where they directly connect and regularly engage with residents, building trusted relationships over time. The CHW model is widely recognized as playing a crucial role for Medicaid beneficiaries by providing personalized support, education, and guidance that empowers individuals to navigate complex healthcare systems, adhere to treatment plans, and address social drivers of health, ultimately leading to improved health outcomes.

Ounce CHWs evaluate residents for gaps in care, host onsite health clinics and screenings, enroll residents in public benefits like Medicaid, SNAP and disability, and connect residents to healthcare and social services, including scheduling primary care and pediatric appointments or helping residents apply for rental assistance. This approach benefits not only residents and Medicaid MCOs, but also property owners, who choose to work with Ounce because it’s a scalable solution that can help them demonstrate positive health and social impact from their property services.

“There is an enormous gap between health plans and where their members spend over 70 percent of their time – their homes. Our highly trained team leverages technology to conveniently engage people where they are, deliver impactful services, and lower healthcare costs for residents and insurers,” said Rachel Munsie, co-founder and CEO, Ounce. “Our success is largely due to the trusted relationships we’re uniquely able to build with residents and the convenience of our services, all delivered within the existing community infrastructure. Our integration with the properties and our proximity to residents gives us the opportunity to quickly intervene with support when we see red flags like eviction notices or other indicators for housing instability, which has clear links to healthcare outcomes.”

Initial Service Launch in Southeast DC

Ounce chose to launch its services in Southeast D.C. before expanding to the rest of the city. Southeast D.C., which is predominantly Black, has higher rates of poverty and gun violence due to chronic underinvestment and has been identified as both a food and healthcare desert. Despite these challenges, Ounce was able to engage and enroll over 30 percent of residents into its program just months after launching, immediately expanding access to care and critical benefits where it’s needed most. Ounce has since maintained engagement rates that are significantly higher than the single-digit rates typical of traditional care models. As a result of this high level of direct engagement, residents who get support from Ounce receive, on average, multiple services at a time. High engagement rates can also be attributed to Ounce’s practice of recruiting CHWs who are from or deeply familiar with the communities they serve.

Strategic Partnerships with with AmeriHealth Caritas DC

In addition to its close partnership with AmeriHealth Caritas D.C., Ounce has partnered with the National Housing Trust, a nonprofit organization that focuses on preserving and improving affordable homes for low-income families. “By combining our expertise in affordable housing preservation with Ounce’s innovative approach to resident services, we are creating a transformative impact on the well-being of our communities, ensuring that quality housing and comprehensive health support go hand-in-hand,” said Priya Jayachandran, CEO of the National Housing Trust. 

Ounce also works closely with D.C.-based providers such as C3Cares and Urgent Wellness, along with several local community organizations including: Bread for the City, Capital Area Food Bank, Giant Healthy Living, Latin American Youth Center, Martha’s Table, So Others Might Eat, UPO Workforce Institute, and many more.

While the need to address social determinants of health (SDOH) is definitely not new, 2023 marks the first year SDOH is codified into national and statewide value-based payment program mandates. These mandates are designed to hold Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs) accountable. While the rollout of SDOH code sets across our healthcare ecosystem is one phase, alone it’s not enough. The next phases are even more critical: codes must be collected, used, reviewed, and acted upon within value-based payment programs to ensure patients realize the benefits of a more inclusive and accessible healthcare system. 

The newest value-based payment program purposely designed to address SDOH is the ACO Realizing Equity, Access, and Community Health (ACO REACH) model, launched by the Centers for Medicare & Medicaid Services (CMS). ACO REACH participants are required to develop a health equity plan to identify underserved patients within their population and implement initiatives to measurably reduce health disparities. While this is not the only requirement, it will challenge ACO REACH participants to collect complete and accurate SDOH data. 

For health plans, they’ll need to sharpen their data collection processes to encompass critical non-medical information. Traditional methods of data collection, such as complex care case management assessments, are no longer sufficient. Payers must have access to and include publicly available data collection aimed to offer a more comprehensive view of a member’s health and social circumstances to comply with CMS guidance. The data payers collect must also be consistent and precise across populations. 

Without standards-based data collection, coding, and uniform information sharing of SDOH data between healthcare providers, health plans (including MCOs) and community-based organizations, it will be extremely difficult — if not impossible — to effectively improve health outcomes.  

States like Massachusetts, New York and Oregon, are leading the way in addressing SDOH data use in value-based payment programs for Medicaid beneficiaries. These early adopters are highlighting how the collection and use of SDOH data leads to better and more equitable health outcomes and the industry is watching. We’ll all learn from how each state addresses the challenges of collecting complete, accurate, standards-based SDOH data, as well as how that information is shared with providers and community-based organizations. With insights from these states, the industry will be better equipped to develop consistent approaches that lead to improved health outcomes and increased health equity. 

While underutilized, one standards-based solution to the challenge of quantifying social, economic, and environmental factors known to affect health and health-related outcomes already exists. In 2021, the CMS Office of Minority Health published data on the use of ICD-10-CM Z codes. Since 2016, Z codes have been available to capture SDOH data at the point of care delivery. Providers submitting claims using ICD-10-CM Z codes to document SDOH have been steadily increasing, from less than 946,000 claims in 2016 to more than 1.2 million in 2019, according to the CMS report. Though that may seem like a large number, as a proportion of the 33.1 million people enrolled in Medicare that year, less than 2% had claims that incorporated Z codes. 

Our current Z code submission rate, while limited, is a great step forward to capture standards-based SDOH data at the point of care for our nation’s most at-risk people; however, more widespread adoption is required to comply with the SDOH requirements mandated in CMS and state value-based payment programs. Look to Standards Development Organizations (SDOs) like the Council for Affordable Quality Healthcare (CAQH) to drive this adoption by adjusting data collection operating rules that define key infrastructure and data content requirements.  One example of this work can be standardizing the submission of ICD-10-CM Z codes on claim transactions to support SDOH data capture at the point of care.  Millions of these claim transactions are already being passed between payers and providers every day.

Integrating SDOH data into value-based payment models also comes with some challenges – beyond figuring out a standardized approach that works. Data privacy and security concerns are paramount, with additional information being collected on individuals. Additionally, there is an abundance of interoperability issues to be addressed at the health IT system level to ensure collaboration and in order to guarantee the seamless exchange of data for maximum outcomes.

As we look ahead, standards-based SDOH data collection — from claims, publicly available information, data from care assessments, integration with clinical notes in electronic medical records, and more — will be essential to remove the barriers to care that value-based payment programs were designed to eliminate. 

We all aim to build a healthcare system that treats the root cause of health disparities, ultimately leading to healthier communities and better health outcomes for everyone. As leading ACOs and MCOs demonstrate the power of harnessing SDOH information to create more equitable and effective care models, the transformative potential of SDOH data promises to reshape the entire healthcare landscape for all. 

About Michael Pattwell

Michael Pattwell is the principal business advisor at Edifecs, a software provider that enables payers and providers to maximize the performance of their value-based contracts and offerings. Michael has more than 30 years’ of experience in health care and currently chairs national value-based payment workgroups at WEDI, CAQH and DaVinci. An author of several articles on our national transition to a value-based payment model and our industry focus on population health management.

During the pandemic, Medicaid enrollment grew by nearly 30% to cover more than 93 million Americans, due in large part to COVID-19 provisions that included continuous Medicaid enrollment. With the unwinding of these pandemic emergency orders, annual cycles of Medicaid redetermination have returned. As a result, states have removed close to 4 million Americans from Medicaid to date. The ongoing redetermination process is likely to expand health inequities across the nation, including in California.

For our most vulnerable communities, Medicaid is a lifeline to care. Medicaid delivers health care, behavioral health, social services, and other necessary resources, by which health care organizers, providers, and community entities partner to deliver better outcomes for enrollees.

The process of redetermination, which relies on the accuracy of demographic data including mailing address and phone numbers, is a prime example of why data collection and management needs to be coordinated responsibly to best improve health at the individual and population levels; within this HIT plays an essential role. In recognition of the procedural burden our existing processes and systems exact, Health and Human Services Secretary Xavier Becerra has encouraged states to use all available strategies to streamline redeterminations and prevent eligible enrollees from losing coverage due to procedural issues. 

Shared health data is the connective tissue that brings together patient medical histories with other social determinants of health (SDoH) data, but it must be the right kind of data: That which reflects whole person care and embraces a co-designed approach to deliver high-quality outcomes. 

Use Data to Advance Access, Not Erect Barriers 

There is an enormous opportunity within the healthcare and social services ecosystem to be more mindful and intentional with data collecting. This can be advanced through better coordination between community-based organizations (also known as CBOs), advocacy groups, and individuals with lived experiences who can share best practices aligned with community needs and preferences. It is also critical to be mindful of where gaps may be occurring, such as the challenges of collecting information, for instance, on the more than 160,000 Californians facing homelessness.

It’s also critical to consider who needs access to this information and how it is used. Data collection and sharing should be used to help providers deliver care more effectively and efficiently; it shouldn’t put individuals at risk of not receiving essential care and services. Sharing health information can feel particularly risky to some populations that have been or still are the target of discriminatory actions and policies, including Black Americans, those seeking abortion services, individuals that identify as LGBTQ+, and minority religions.

Why We Need Whole Person Care

Whole person care is a proactive, modern approach in which health is viewed holistically. It considers not only health information, but also behavioral health and SDoH. A more comprehensive understanding of the connections between genetics, environment, access to nourishing foods, wellness and disease also helps impact health through the influence of behaviors, environments, and policies. In this approach, patients and doctors share decision-making and benefit from a variety of care delivery methods, such as virtual appointments, community resources and in-home care. 

There is already momentum at the federal level to prioritize whole person care. We are seeing a growing number of policies and regulations aimed at improving services for historically overlooked communities, including Section 1115 Medicaid waivers that expand coverage and reduce health disparities. In California, whole person care is a central component of the transformation of Medi-Cal through CalAIM, which is focused on delivering to the state’s 15.3 million Medi-Cal members a more equitable, coordinated, and person-centered approach to positively influence their health and life trajectory. 

Co-Designed Solutions for Better Health and Wellbeing 

In the context of redetermination, sharing data across healthcare and social services allows providers to have the latest, most accurate health data and contact information on Medicaid enrollees so they can properly support them throughout the redetermination process. Maryland is already using its state’s health data utility to prevent gaps in care. Additional partnerships with managed care plans, CBOs, and shared data from the United States Postal Service to update contact information also helps. 

Delivering equal access to information creates a stronger system that prevents high-risk individuals from falling through the cracks. This equality supports stronger alliances between health plans, hospitals and health systems, providers and social needs intermediaries, such as community health workers, CBOs, peer support specialists and behavioral health experts who can serve as navigators between health and social services.

Within co-designed solutions, health plans support access to care and resources by building trust and working closely with providers, the community, and others on the frontlines. It shifts the focus from tracking down and verifying information to collaborating on which care levers most effectively lead to the best outcomes.

A Brighter, More Equitable Future is Ahead

The health care system relies on accurate data and information to provide essential care for our country’s most vulnerable populations, and no example is more clear than in our Medicaid redetermination cycles. If data is inaccurate, outdated, or inaccessible, individuals will become ineligible.

Beyond eligibility, inaccurate information has the power to negatively affect the quality of care received across the healthcare and social services landscape.

We have an exciting opportunity—and urgency—to create more inclusive processes and systems, powered in part by HIT, that recognize and advance health equity within populations while implementing insights based on existing data. It’s time for all of us involved in healthcare to recognize our role and responsibility to use all data, past and future, for good. 

About Adimika Arthur

Adimika Arthur is the CEO and Executive Director of HealthTech for Medicaid (HT4M). She is a visionary and strategic executive who has spent over two decades in healthcare and whose research experience in health equity, investments and disruptive technologies provides companies insights while competing in a rapidly shifting market. 

About Manisha Sharma, MD, FAAFP

Manisha Sharma, MD, FAAFP is the Senior Medical Director, Promise Health Plan at Blue Shield of California. Sharma is a board-certified family medicine physician who works at the juncture of patient care, community health, social justice, health policy, and innovation. She is committed to “being the change” in how healthcare is delivered in the United States.

What You Should Know: 

• ZeOmega announced it has integrated its Jiva Population Health Enterprise Management Platform’s SDOH Social Care solution with Microsoft Cloud for Healthcare built for Microsoft Azure. 
• The integration empowers healthcare organizations with Azure to achieve increased access, seamless compatibility, and unmatched administrative efficiency, enabling smoother processes and freeing healthcare professionals to prioritize exceptional patient care. SDOH takes center stage with data visualizations for informed decision-making and understanding patient needs. The measurement dashboard provides a comprehensive view of SDOH outcomes, empowering continuous improvement for optimized patient outcomes.

Integration Benefits

Social determinants of health (SDOH) such as lack of transportation and food insecurity are said to impact 50 percent of health outcomes. When patients face hurdles in adhering to care guidelines, even minor conditions can spiral out of control and lead to costly hospitalizations and procedures. The breadth and depth of ZeOmega’s SDOH data sources gives care coordinators and clinicians a complete, at-a-glance view of social needs by area, population, and individual so they can strategize and deploy appropriate interventions. Integration with Cloud for Healthcare and Microsoft Power Platform will enable case managers, clinicians, and other healthcare professionals to work from a single unified platform where they can access high-level visualizations of social, clinical, and behavioral information and take appropriate action within their existing workflows.

“Our SDOH solution integrated with Microsoft Cloud for Healthcare will help clients deliver even more effective and efficient member engagement as they identify risks and needs across geographic areas, populations, and at an individual level,” said Pravin Pant, MSHI, Vice President of Advanced Analytics, ZeOmega. “Equipping our robust platform with the capabilities of Microsoft Cloud for Healthcare and Power Platform functionality expands healthcare leaders’ access to actionable insights to develop precision strategy, and improve patient outcomes and ROI for their organizations, all from one unified workflow.”

What You Should Know: 

• UnitedHealthcare, today announced it is awarding $11.1 million in grants to 66 nonprofit organizations across 12 states through its Empowering Health program. 
• These grants address social determinants of health (SDoH) and help uninsured individuals and underserved communities. 
• Since launching its Empowering Health commitment in 2018, UnitedHealthcare has invested more than $62 million in Empowering Health grants reaching more than 11 million people through partnerships with community-based organizations in 30 states and the District of Columbia.

Addressing SDoH to Serve Underseved Communities

The grants will help those struggling with food insecurity, social isolation, behavioral health issues, improve health literacy efforts and more.  The grants include:

• $300,000 to Community Servings in Massachusetts to research, design, pilot and test a Step-Down Program that will support clients as they transition off a medically tailored meals program.
• $300,000 to CHRIS 180 in Atlanta, Georgia to support trauma-informed mental and behavioral health and social services through a community health worker program for low-income residents of Atlanta’s westside.
• $200,000 to Consejo Counseling and Referral Service in Pierce County, Washington to support the addition of culturally relevant wellness programming to support all aspects of mental and physical well-being for youth and families across Pierce County and rural areas.
• $200,000 to Trellis in Minneapolis and St. Paul, Minnesota to reduce social isolation among people living with memory loss and their caregivers with targeted outreach to convene community leaders to provide input, complete needs assessments, develop culturally appropriate materials, identify areas of greatest need and host community events bringing awareness to memory loss and providing practical solutions for addressing social isolation.    
• $165,000 to The Update Foundation in Syracuse, New York to support the Upstate Medical University’s “She/We Matter Program”, a peer-to-peer community outreach program designed to reduce health disparities by making health screenings, particularly mammograms, a priority among low-income Black and Latinx women.
• $65,000 to The Providence Center in Rhode Island to strengthen community-based mental health services by expanding the specialized “Emergency Services Program” for children.

In an interview with HIT Consultant, Dr. Gary Rothenberg, Director of Medical Affairs at Podimetrics talks about how healthcare technology can help support a focus on social determinants of health (SDoH) to enhance the relationship between the patient and physician/care team.

How can health technology play a role in helping to address social determinants of health (SDOH) when it comes to diabetes care?

Dr. Gary Rothenberg, Director of Medical Affairs at Podimetrics: While I am a big believer in the value of technology in building a new healthcare ecosystem that is focused on value versus filling hospital beds, I think this is a long play. 

Today, patients — including those living with diabetes who I support in my role as a clinician, in academia, and as a director of medical affairs — are facing debilitating issues specific to SDOH. These SDOH challenges vary greatly — from not having enough money to buy their much-needed insulin to not having a car to get to a doctor’s appointment.

While tech can and must have a role to play — including helping to identify the most at-risk patients we can target for support — we, as clinicians, have a huge role to play ourselves as leaders of the patient care team. Being an effective healthcare provider is still a human skill to practice and perfect. It requires that we talk to people, touch them with our hands for examinations, and troubleshoot their fears and concerns.

The critical role of community health has been around for a few decades within U.S. health systems. If community health work was the answer to addressing SDOH, wouldn’t we be further along in solving these problems by now?

Dr. Rothenberg: Short answer, no. The population of people facing SDOH challenges has continued to grow year over year, and the pandemic only further exacerbated these issues — especially for those who were already vulnerable before COVID came our way. In tandem, we haven’t had the increases in investments specific to community health work to keep up with this rising demand. 

Essentially, we have a pretty significant supply and demand issue at hand — meaning more people needing support and fewer community health workers and related resources to support them.

We need more government investment in community health — particularly in relation to workforce investments — in order to significantly transform community care. Also, the focus must be on value, not fee-for-service, in order to drive toward measurable, long-lasting change for patients living with SDOH challenges.

How is health technology, and in particular health tech using AI, uniquely able to address issues pertaining to SDOH?

Dr. Rothenberg: I mentioned risk stratification before. AI has a specific role to play here. The reality is that the healthcare industry — and clinicians in particular — are rich in data but poor in insights — meaning that while we have access to a lot of data, there’s not much knowledge we can derive from that data today when and where we need it most.

This is where I see a huge opportunity for AI — in being able to cull through massive amounts of data, derive actionable insights, and provide those insights to the care team at the point of care and/or before an in-person or virtual consult.

With the appropriate training and clinical guidance, AI can and should play a huge role when it comes to big data and layering on analytics with the end goal being to support the healthcare system’s transition to preventive, proactive care.

Interest in the potential of health tech, and specifically the use of AI, and its ability to address long-standing challenges such as SDOH remains high. Is AI a strong answer to the problems associated with SDOH identification and support? 

Dr. Rothenberg: AI isn’t the end-all, be-all answer to addressing SDOH. It is, however, an enabler of innovation that can help drive a much-needed change in identifying our most vulnerable patients and getting them access to the type of care that fits their needs and focuses on value. Still, that’s going to take more time. And while I am just as excited as others about ChatGPT, I still don’t think it’s ready for healthcare prime time.

There are other non-AI types of innovation specific to SDOH that excite me personally and have nearer-term potential — for example, the “food is medicine” movement and the related recent announcement from Instacart Health. 

Building on this announcement, Boston Children’s Hospital is now among the first health systems to leverage Instacart Health provider products for its patients, establishing new food-as-medicine programs to help them get the nourishment they need to manage and maintain their health. Food plays such a crucial role in our health and well-being, and the idea that technology can break down access barriers to nutritious foods truly holds the potential to prevent serious and costly chronic diseases like diabetes — a disease that adversely impacts people of color today in a very significant way.

What is the future of health tech in relation to addressing SDOH? 

Dr. Rothenberg: The future of health tech when it comes to addressing SDOH should look like this in healthcare:

• Preventive — Tech identifies the patients most at risk of health issues;
• Proactive — Tech helps clinicians and care teams simplify engagement with these patients early and often;
• Personalized — Tech helps improve patient experience and offer insights/support in a personalized, patient-centric way from the comfort of their home when possible; and
• Passionate — Tech should help make people interested and excited to engage and participate in their own care and well-being, and it should, in turn, reignite the passion for patient care with physicians as well.

About Dr. Gary Rothenberg
Dr. Gary Rothenberg is a board-certified podiatrist with more than 20 years of experience that includes academia, clinical practice, and research. His research focuses on preventing lower extremity complications associated with diabetes. As Podimetrics’ Director of Medical Affairs, he also serves as an Associate Professor of Internal Medicine in the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan. He graduated from the Ohio College of Podiatric Medicine and completed his primary podiatry medical residency training and podiatric surgical residency at the University of Texas Health Science Center.

What You Should Know:

• Pear Suite, a digital health company empowering community health workers (CHWs) to improve health in Asian American and Pacific Islander (AAPI) communities and address social determinants of health (SDOH) raises $2.5M in seed funding. The investment round was led by Mucker Capital, Impact Engine, American Heart Association, Sweater Ventures, and Atento Capital, with support from Techstars, Open Venture Capital, Incisive Ventures, Lair East Labs, StartUp Health, and Third Act Ventures.
• Launched in 2021 by co-founders Colby Takeda and Nick Lockett, Pear Suite’s flexible and customizable social care navigation platform enables anyone – CHWs, care coordination staff, volunteers, and others – to better assess and address SDOH in a cost-effective, person-centered, and culturally and linguistically sensitive way.

 Social Drivers of Health. Simplified.

Through AI-powered smart scripts and care journeys, omnichannel communication tools, predictive analytics, and actionable dashboards to guide resource linking, Pear Suite is converting SDOH data into real-time solutions for CHWs to drive impactful interventions for those in need, particularly those within the AAPI community. To date, the company has helped over 24 organizations boost member engagement, improve health outcomes, and reduce the overall cost of care, impacting more than 25,000 individuals.

Expansion Plans

The seed funding will support platform development, expand efforts within AAPI communities, and forge partnerships with organizations serving underserved populations. Pear Suite aims to impact an additional 300,000 lives through collaborations with health plans, providers, and community-based organizations.

The VBC delivery model encompasses various approaches with the most common being Accountable Care Organisations (ACOs) and Integrated Delivery Networks (IDNs) in the US and  Integrated Care Systems (ICS) in the UK.  Both countries’ approaches are networks of healthcare providers (hospitals and physicians) who work together to deliver high-quality coordinated care to beneficiaries while controlling costs.  The benefits of VBC models include better patient health outcomes at a lower cost, streamline delivery via coordinated care teams, focused preventative care and treatment plans for patients, less physician burnout, lower costs for payers, and a healthier patient population due to better adherence to treatment.  

While there are many benefits to VBC, there are also some significant obstacles that must be overcome for this type of healthcare delivery model to be a success.  This includes dealing with disparate IT and health records systems, outdated workflows, and lack of internal resources which is a consequence of patients seeing multiple physicians, specialists, etc. who are using different data handling platforms throughout the course of treatment.

When it comes to VBC IT solutions, there are six tools that are essential for tracking, monitoring, and measuring patient outcomes.  These include IT tools to identify patient cohorts, segment patients by risk, aid clinical decision-making, manage care coordination, carry out patient activation, and finally, measure performance and report outcomes.  

Over the years, Signify Research has had the opportunity to speak to 100s of VBC decision-makers and buyers from ACOs and IDNs in the US and similar organizations internationally about their healthcare IT needs.  Our conversations with these organizations have provided greater insights into the current drawbacks of utilizing these technologies as well as what needs to change to improve these IT tools for the better. 

Tools to Identify Patient Cohorts

Our research has highlighted that electronic health record (EHR) systems are the main sources of patient information that are used to identify specific patient cohorts to target as part of VBC, coupled with manual data handling processes.  EHR systems can vary across providers’ settings, with some being more basic with limited clinical decision support (CDS) on offer including minimal highlighting of care gaps and no priority ranking of patients or insights on the financial impacts of closing these care gaps.  EHR systems that are more advanced tend to provide modules that have robust CDS that highlight actions to prioritize patients and provide some input on the cost impact of closing care gaps.  

However, gathering this information to identify patient cohorts to target for VBC is not always a straightforward process.  A majority of ACOs and IDNs that leverage EHR systems to identify patients use a mixture of DIY business intelligence tools such as Tableau, PowerBI, and Excel, for example, combined with some form of a dedicated commercial health insights solution drawing on EHR data.  This process is not straightforward and involves interrogating multiple data sources in various locations to develop a fuller patient view that includes manually pulling data from EHRs/Data Warehouses, claims portals (US-only), self-developed DIY tools, and social determinants of health (SDoH) tools.  Having to pull in data from multiple sources manually does not always display in a way that can help these organizations clinically, especially when some of the data is insignificant or inaccurate.    

When identifying patients to target for VBC, key things that care management teams look at include frequency of hospital admissions/readmissions, frequency of ED visits, type and number of chronic conditions, social needs data, medication spending, and screening tests.  As VBC organizations continue to grow and mature, the demand for more data points beyond EHRs is becoming increasingly important to help accurately identify patients to close care gaps.  With this comes growing interest in the need for sophisticated IT tools that automate processes and improve current workflows. 

Tools to Risk Stratify Patient Cohorts

The VBC providers we have spoken to have highlighted a reliance on several off-the-shelf algorithms that are used to segment patient cohorts identified from EHRs into high-risk/low-risk categories as a way of prioritizing who needs immediate interventions and care plans.  The algorithms in use include, for example, Milliman RX, Hierarchical Condition Category (HCC), Charlson Comorbidity Index, QAdmission Risk Algorithm (UK), Electronic Frailty Index (UK), and Kaiser Triangle.

The reliance on these algorithms once again requires care management teams to utilize manual data handling processes that include a mix of self-developed business intelligence tools combined with some health insights software.  As risk stratification is an important part of VBC, most organizations are currently not using sophisticated tools for various reasons related to issues of cost and lack of internal resources.  But the interest and need are there to look at IT tools that can improve workflows and help to focus on high-risk, high-cost patients in a more efficient and less laborious manner.

Clinical Decision Support Tools

Across VBC organizations we have engaged with, there is a wide variety of CDS software tools in use depending on where the ACO, IDN or other organization is based on their IT set-up journey.  Some have minimal or no CDS tools for closing gaps in care and rely entirely on manual processes to find and prioritize patients for care plans.  Other organizations have CDS support in the form of limited actionability that provides some software assistance with identifying cohorts but still requires manual work to input/extract relevant patient data.  The most advanced VBC organizations have developed integrated tools/dashboards that are combined with cohort identification and risk stratification IT tools and CDS modules providing care gap closure recommendations. 

While advanced CDS setup is what most organizations aspire to, the system is still not perfected as many CDS options are not integrated with care coordination team workflows requiring timely manual processes and additional staff resources.  There is a growing demand for the use of mature, integrated tools that mirror the VBC journey and bundle cohort identification, risk stratification, and CDS in health insights into one seamless end-to-end workflow.  

Population Health Management Tools

Another health IT needs includes improvements to current population health management (PHM) tools on the market.  Many organizations currently use broader dedicated PHM tools that enable care management teams to view cohorts based on risk and then drill down into specific patients to receive input and advice on what actions are needed to close gaps in care.  This specialized software allows for data visualization of common actions across cohorts that would lead to the greatest impact from a financial and clinical perspective.  

While dedicated PHM software is mostly used in medium to large-scale VBC organizations, many of the buyers we have spoken to have highlighted the dissatisfaction that cohort ID is mostly from siloed data sources that are not always accurate or up to date which increases the potential for patients to be incorrectly prioritized.  Also, many of the tools are not as user-friendly and require dedicated support from the IT/informatics team to manipulate data.  The demand is for solutions that not only provide a holistic patient view but also can be easily manipulated by care management teams without having to rely on technical or informatics expertise.  

Patient Activation and Outreach Tools

Our conversations with VBC decision-makers and buyers have also illustrated that despite the demand and use of IT tools for PHM, the telephone remains the primary method of contacting patients and enrolling them into VBC.  Enrollment success varies greatly across organizations, with some leveraging additional outreach tools such as texting tools and various patient apps and portals to contact patients.  

Patient communication is initiated and managed via workflows that once again originate from the EHR which houses patient contact information.  Organizations that have smaller, less diverse populations and those who have either invested in specific PHM IT tools to manage the process or who have developed their own in-house IT tend to experience higher patient enrollment in VBC.

However, while not high on the IT improvement wish list, many VBC buyers have expressed a desire to access outreach tools that better integrate with other care coordination workflows to streamline and expedite patient outreach activities and generate engagement.  

Reporting and Performance Tracking Tools 

To judge the eligibility of ACOs and IDNs for reimbursement payments and shared cost-savings, these organizations are required to participate in annual audits that measure performance and track outcomes.  Analyzing data for these audits is extremely valuable, but it tends to be a labor-intensive process and many healthcare organizations lack adequate resources and skill sets to create these reports.

Currently, most organizations use some form of DIY BI tools created by internal staff to track various program success metrics and KPIs around strategy, operational, and process improvements.  Most medium-to-large scale organizations rely on internal data analytics/informatics teams to develop IT tools via Tableau, Excel, Qlik that provide details on specific performance measures. 

This method of reporting again requires an abundance of manual tracking/reporting activities with automated tools used less commonly.  And this reliance on specific data analyst teams creates a backlog of reporting which makes it impossible to monitor performance in real time so strategies can be implemented to correct or improve outcomes before year-end.   

What PHM solutions are truly needed?

In summary, the six types of health insights IT tools that are essential for VBC organizations are not without significant drawbacks.  What is clearly not working is the lack of a holistic 360-degree patient view, and data limitations in terms of latency and access with multiple data feeds leading to missing and outdated patient information.  With the variety of vendor PHM IT tools in use that are falling short and still need to rely on manual processes, there are growing challenges in creating clear, coordinated workflows that share information back and forth between care management teams and frontline providers.  

Our conversations with VBC healthcare leaders have illuminated three key purchase drivers for any PHM IT tool which includes examining how these tools improve patient care, improve clinical staff workflow/efficiency, and reduce data fragmentation/data siloes.  What is needed for VBC are IT tools that ensure actions recommended by dedicated care management teams are visible and front-facing for providers to act upon as they interact with patients.   Also, having real-time data feeds and tools to inform care management would be extremely beneficial to VBC organizations in terms of monitoring and improving healthcare outcomes.

About Rohinee Lal 

Rohinee Lal is the Principal Analyst at Signify Research, a research advisory company providing healthtech marketing intelligence powered by data. Rohinee joined Signify Research’s Custom Research & Consultancy team in early 2022. She brings over 24 years of experience collecting, analyzing, & presenting market intelligence across various industries including pharmaceuticals, medical devices & digital health.

HealthJoy, Teladoc Health Launch Virtual Primary Care

HealthJoy, a benefits navigation platform that amplifies employer benefit strategies expands its partnership with Teladoc Health to introduce virtual primary care. HealthJoy Virtual Primary Care, powered by Teladoc Health, provides a fully integrated primary care experience that supports members throughout their entire healthcare journey. The solution will further enhance HealthJoy’s comprehensive suite of virtual care offerings that already includes adult and adolescent mental health, chronic care management, dermatology, employee assistance program services, musculoskeletal therapy, nutrition, tobacco cessation, and urgent care.

Lifesum and ŌURA Partner to Connect Nutrition and Sleep

Lifesum, the leading global healthy eating platform, has unveiled a sleep tracking feature in partnership with ŌURA, the company behind the smart ring that delivers personalized health data, insights, and daily guidance, which will allow its users to understand how their dietary choices impact their sleep patterns—and vice versa. The partnership will build on their integration of Health Connect by Android to give Lifesum users another important layer of health data to track. The sleep tracker function will be offered to Lifesum Android users who opt in to the open beta, and the company will roll out the service to all Android users in the coming weeks.

Neuronic and Santa Clara University Partner to Develop Next-Gen Neurotech for Photobiomodulation

Neuronic, a multi-national company focused on light therapy technology, and Santa Clara University (SCU) in Silicon Valley announced a partnership to develop a research project to study photobiomodulation (PBM) guided by real-time brain activity, which will be led by Dr. Julia A. Scott and Dr. Sally Wood.  To address this concern, the research team plans to improve the efficacy of PBM delivery, a non-invasive therapy that uses near-infrared light to pass through the skin and activate molecules that improve blood flow, reduce inflammation, and increase cellular energy.

The researchers hope that their findings will pave the way for more conclusive evidence regarding the effectiveness of PBM for brain injury and neurodegenerative conditions. Further, they envision a future where clinicians can tailor treatments to the individual needs of each patient through the use of real-time electroencephalogram (EEG) data, thereby optimizing results. To achieve this goal, the team will conduct small-scale studies of the device on healthy adults to assess the effects of PBM on brain activity and evaluate protocol designs.

Patient Discovery Partners with AmerisourceBergen for Cancer Care Equity

Patient Discovery Solutions joins global healthcare company AmerisourceBergen’s Trusted Vendor Program. The collaboration enables community oncology practices, hospitals, and health systems nationwide access to Patient Discovery’s Equitable Care Platform, allowing care providers to proactively identify and address social determinants of health to better inform providers and help improve outcomes for cancer patients. AmerisourceBergen’s Trusted Vendor Program is comprised of a portfolio of cutting-edge operational and clinical care solutions. As a partner, Patient Discovery’s Equitable Care Platform will seamlessly integrate within a participating practice’s current systems, helping to improve information exchange for delivering equitable care across multiple sites of care.

Opus EHR Partners with Aroris to Revolutionize Behavioral Health Practices

Opus EHR, an innovative behavioral health solutions provider partners with Aroris, a contract negotiation company, to provide cutting-edge technology solutions that help behavioral health practitioners save time and money while managing payer relationships more effectively. The partnership aims to equip both current and prospective clients with all the necessary tools and features to grow and scale their practice, optimizing profitability from their business efforts.

Doceree Further Expands Global Footprint With Partnership With Hello Health Group 

Doceree, a global platform building unprecedented solutions for HCP programmatic marketing with proprietary data tools, today announced its long-term partnership with Hello Health Group, a leader in health & wellness content development that drives consumer and patient engagement. The latest collaboration will accelerate growth for both companies by combining the world-class HCP targeting and reach capabilities of Doceree with Hello Health’s leading patient and consumer reach and engagement solutions, and strong geographical presence in the South East Asian region. The partnership further establishes Doceree’s presence in eight key markets – Vietnam, Indonesia, Malaysia, Cambodia, Myanmar, Singapore, Philippines and Taiwan.  

West-Com Nurse Call Systems, Vitalchat Partner to Bring AI-Enabled Virtual Care Solutions to Healthcare Facilities Nationwide

West-Com Nurse Call Systems and Vitalchat partner to provide hospital systems and other healthcare facilities nationwide with virtual care solutions using artificial intelligence to meet the needs and demands of patients, caregivers, providers and IT leaders. Together, these solutions increase patient and caregiver safety, improve clinical collaboration, enable specialty access and provide for off-site family connection and engagement. They are available through a network of more than 70 active distributors around the country.

• Get Well, a global leader in digital patient engagement, today announced it has expanded its industry-leading digital patient engagement portfolio to include new social determinants of health (SDOH) screening solutions.
• The new solution will be available to more than 200 enterprise healthcare organizations nationwide that are using GetWell Inpatient, an interactive patient care and hospital experience management product, at no additional cost.

Enabling Enterprise Healthcare Organizations to Meet New CMS Requirements

“Today, 80% of health outcomes are driven by non-clinical factors such as physical environment and health behaviors. We need to reimagine the ways we are reaching and engaging patients and do so in a way that is still seamless for overburdened clinicians,” said Michael O’Neil, Get Well CEO. “At Get Well, our mission is to provide high-quality personalized patient care, educate families, and empower clinicians. This starts with better understanding the needs of all patients, particularly underserved patient populations, and enabling our valued partners to leverage these insights in a meaningful way to meet new and evolving regulatory requirements.”

In 2024, CMS and many states will require hospitals to implement SDOH screenings for all patients 18 years and older. The Joint Commission and NCQA have also created requirements or reimbursement incentives to screen and support social needs. In response, Get Well now offers a new suite of features that help automate the screening of SDOH and navigate patients to appropriate resources:

1. Use existing tools to collect SDOH data: Through Get Well’s interactive TVs, client partners can allow patients and caregivers to confidentially complete social needs surveys.
2. Add additional channels for scale: Patients can now also complete SDOH surveys on their phone via text messaging, tablets, or mobile devices, or during tech-enabled staff rounding with GetWell Rounds+.
3. Seamless integration into existing EHR: Directly embedded SDOH screening data into Epic, Oracle Cerner, and other EHRs ensures coordination of data and workflows.
4. Escalate and triage social needs: Care teams can monitor patients in real-time, pinpointing intervention opportunities, and triaging needs to appropriate care teams.
5. Navigation of patients to the social resources they need: GetWell Navigators — virtual, and digitally enabled by the Get Well platform — can guide patients to local resources via texting or phone, reducing the workload for overburdened care teams and closing the loop on community referrals. The “high-tech, high-touch” combination sets the GetWell SDOH solution apart.