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Data and Person-Centered Approach: Identification and Tracking for Higher Levels of Health Related Social Needs


To empower Community Health Navigators (CHN) with enriched data, increasing their efficiency and ability to manage HRSN needs for a larger panel of people with less stress, Activate Care uses a person-centered and integrated data approach of identification, prioritization and segmentation, along with advanced data analytics.  

In a previous blog post, we introduced the mission of Activate Care and how Activate Care supports Medicaid or Medicare beneficiaries (clients) through CHN. The organization's focus on helping individuals access essential HRSN services such as housing, transportation, food, community safety, and employment training is important, as these social factors can significantly impact overall well-being. 

The previous post also introduced the basic process of data collection and analysis, while this blog aims to discuss the key components that assign each member to a specific health and social risk level to identify their individual HRSN and follow-up. 


Client Recruitment: Activate Care uses a variety of tools to connect with hard-to-reach clients. Activate Care’s marketing efforts may include a variety of recruitment methods, such as SMS, email, social media, direct mail, outbound calling, or through local community events, health fairs, health clinics, or other public venues. The recruitment process may include self-referral or community-based referrals, including healthcare providers, insurance payers, and public agencies. 

A Completed Health and Social Risk Assessment is used to gather information about the health and social needs of the members after they are recruited. Activate Care uses the standard screening tools and some additional questions, to assess these domains: health care, food, housing, child care, transportation, health literacy, companionship, legal assistance, goods, education, and employment. The screening tools are aligned with the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) standards for data collection and outcome measure tracking.  

Predictive Prioritization Model: Activate Care has developed a custom-built predictive artificial intelligence (AI)/machine learning prioritization model to engage members who can be most impacted, as captured by clinical and social risk factors and how many barriers we can remove. The following factors from historical data are included in the model:

Historical Medical Utilization: Inpatient, readmission, emergency department visit (ED) or significant high medical cost, no primary care (PCP) or dental visit.

Clinical and Behavioral Factors: Multiple chronic conditions such as diabetes and hypertension; Substance/opioid abuse; Mental health conditions such as bipolar disorder and major depression; Disability: Individuals with intellectual or developmental disabilities; Polypharmacy: The use of multiple medications by an individual, typically involving the concurrent use of several medications to manage various health conditions, and a significantly higher numbers of physicians prescribing medications to the patients; Not on appropriate medication: Individuals do not take their prescribed medications as directed by their healthcare providers due to the challenges of managing multiple medications, lack of understanding of medical literacy, or lack of transportation to get the medications etc.; Lack of motivation in health-promoting behaviors: An individual's motivation level to engage in behaviors or activities supports their health and well-being, and thus to be closely related to their health outcomes. The most risky factors we observed for individuals not taking care of their health are:

    • Income
    • Their own financial stability and community financial stability
    • Indicating the close links between health and social factors. 

Social Needs identified from Risk Assessment: housing, transportation, food, etc., including individuals who are chronically homeless, members in foster care and adolescents with special needs.

Other Social Factors: Age, sex, marital status, race or ethnicity, area that individual lives, total historical economic risk: an individual’s financial risk over the next 12 months, without using any clinical data.

Tailored Approach: Based on the results of the health risk assessments and the predictive prioritization model, Activate Care's CHNs provide a tailored approach to each member. This includes determining the level of intensity and delivering the support needed, which could range from assistance with basic needs like food, housing and transportation, community resources, and access to healthcare services, including PCP and dental visits. Additionally, public health professionals by Activate Care conduct a structured, community-engaged assessment of local community resources and service experiences to ensure the community’s ability to address member’s HRSNs and their health equity barriers. 

Data Monitoring: Data including outreach and recruitment, screening, intake, follow-ups, and graduation across programs is monitored to build the reports for operational efficiencies and reports to drive clinical decision support. The key health equity outcome measures include assessing self-efficacy and confidence, access and timeliness of social need care, medical resource use and cost, client experience and satisfaction, engagement in care, quality of care by HEDIS, etc. These decision supports can be shared with a health plan’s care management team or other partners to allow efficient coordination and communication among staff, partners and members.

Below are a few examples of Client Experiences from Activate Care’s social intervention program, Path Assist. 


Charlie B *  is a 55-year-old male with a $30k annual income and Medicaid benefits. He has major depression, alcohol-related disorders, anxiety, uncontrolled type 2 diabetes, and kidney disease that requires dialysis. He has medical literacy challenges, dental concerns, and lacks transportation. He had 5 ED visits in the past year due to medical issues. Activate Care CHN assisted Charlie with scheduling PCP, dentist and medical specialties to control his depression, anxiety, diabetes and explained how to take certain medications. Connecting to transportation resources by Activate Care CHN allows him to access healthcare services, dialysis centers, and pharmacies and to find retail locations where he can use his limited income to buy healthy, low-salt, and low-fat food.


Amanda H *, a 35-year- old single mother. As a teen, she was in and out of mental health facilities and was stuck in an intimate relationship involving drugs. She lived in homeless shelters with her three little girls in and out of foster care. She found herself with a painful breast lump last year. Activate Care CHN helped her to find a PCP and eventually a cancer specialist doctor plus a mental health doctor to control diseases. She was treated successfully and recruited to work as a CHN peer herself to help people like her to navigate the health system and financial assistance. CHNs also provided some legal aid to manage the legal issues of her kids and family relationships. The income and other social support allowed her to rent her house with three children and restored her self-efficacy. 


Overall, Activate Care takes a data-driven and person-centered approach to improve the well-being of Medicaid and Medicare beneficiaries by providing them with targeted social support and healthcare services through CHN. This approach aims to reduce medical claims cost, inpatient admits, and ED visits, thus enhancing the overall health outcomes and quality of life for these individuals, eventually restoring people’s self and social efficacy. For CHN-led programs similar in design to Activate Care, 15%-54% reduction in ED visits, 15-42% reduction in inpatient admissions, and 29%-43% lower in hospital days were reported in the reference below. These outcomes reflect the benefits of such programs in improving patient care and reducing healthcare costs.  



* The names have been changed to protect client confidentiality.