Address social-determinants of health (SDOH) with in-home and telephonic outreach that helps to overcome barriers to health, including food insecurity, slip and fall risk, access to transportation, social isolation, and ability to afford medications.
Connect members and facilitate collaboration with social service organizations within the community, as well as the broader health ecosystem, using a collaboration technology platform that complies with State and Federal legal and privacy regulations. Our platform enables outcomes-focused networks designed to address social determinants of health, helping to close gaps in care and improving well-being through support for non-clinical needs.
Our enhanced in-home health evaluation solution breaks down the traditional barriers between clinical and community care, allowing healthcare and social service agencies to work collaboratively within a privacy-enabled model that connects upstream social interventions to patient outcomes and plan performance goals.
Segmentation & risk scores
Identify social risk with predictive SDOH analytics, in-home health evaluation data, and clinical assessments to improve outcomes.
Coordinated social care networks
Rely on our nationwide network of community- and faith-based organizations through support from our specialized team of social care coordinators.
Ensure information exchanges across community-based organizations (CBOs) and healthcare providers are secure and compliant.
Document clinical and social information in real-time longitudinal records for a single, complete picture of each person’s health status.