Empowering healthcare organizations with integrated virtual care solutions that improve care coordination, reduce total cost of care, and drive success in value-based care.
Social determinants—such as access to food, housing, transportation and social support—have a profound impact on health outcomes. CMS is implementing a Health‑Related Social Needs (HRSN) screening tool to identify beneficiaries’ needs and reimburse providers for these assessments. Care management programs like CCM, BHI and TCM are well positioned to engage patients, screen for SDOH and coordinate.
Use standardized tools (e.g., G0136) to assess social needs and document Z‑codes for appropriate reimbursement.
Incorporate SDOH data into AI models to prioritize interventions.
Connect patients to community programs (food banks, transportation, financial assistance, housing) and track referral completion.
Pharmacists, social workers and care coordinators collaborate to address social barriers and medication access issues.
Provide education and coaching to help patients overcome social challenges and adhere to treatment plans.
Addressing social needs reduces disparities and improves outcomes for underserved populations
SDOH interventions contribute to higher quality scores in value‑based programs (Star Ratings, CAHPS, HEI)
Billing for HRSN assessments provides additional revenue
Removing barriers enables better adherence and reduces preventable hospitalizations and ED visits
Our SDOH support program integrates social needs screening into routine care management workflows. Using AI‑driven risk models, we identify social barriers that impact medication adherence and disease control. Our care coordinators and social workers then connect patients with appropriate resources and monitor outcomes.