Empowering Community Navigators to Bridge the Gap Between Healthcare Services and Social Determinants of Health for Individuals in Need

Path Assist was developed by Activate Care to address inequities in healthcare that exist in Medicaid beneficiaries by addressing health-related social needs (HRSN) within the population. A growing body of evidence demonstrates that Medicaid beneficiaries who are more actively involved in their healthcare experience have better health outcomes and incur lower costs. As a result, many public and private healthcare organizations employ strategies to better engage Medicaid members. 

Activate Care hires and trains community health navigators (CHN) in the community and empowers them with data, technology, and a proven intervention (Path Assist) to engage individuals in care. The Path Assist program supports these beneficiaries to obtain, process, communicate, and understand basic health information and services. Path Assist addresses the following HRSN (but not limited to): housing, transportation, food, community safety, employment training, etc., based on standard definitions from agencies, such as the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). 

Individuals with Disabilities: Individuals with disabilities may face challenges related to mobility, cognitive impairments, or caregiver support, affecting their medication management. The Path Assist program ensures that individuals with disabilities have access to essential services. This includes advocating for accessible transportation, public facilities, and healthcare services.

Housing: The Path Assist intervention can provide support and resources for individuals who are experiencing homelessness or facing housing insecurity. This may include connecting them with shelters, affordable housing options, rental assistance programs, or case management services.

Transportation: The program recognizes the importance of reliable transportation for individuals to access employment, education, and other essential services. Individuals may be offered transportation assistance programs, such as public transit subsidies, ride-sharing vouchers, or assistance obtaining driver's licenses or car ownership.

Food: The significance of food security is addressed through the program, and CHNs offer assistance in accessing affordable and nutritious food. This can include referrals to food banks, community gardens, meal programs, or enrollment in government assistance programs.

Community Safety: Path Assist aims to create safer communities, and CHNs may collaborate with local law enforcement or community organizations to promote safety initiatives. Other educational programs, resources for conflict resolution, or referrals to victim services for individuals impacted by crime or violence may also be offered.

Employment Training: The program can provide support in developing job skills, accessing vocational training programs, or connecting with job placement services. This can include resume writing assistance, interview preparation, skills assessments, and referrals to relevant training opportunities.

Chronic Diseases, Mental Diseases, or Substance Use Issues: Individuals with multiple chronic diseases and mental health disorders, including depression, anxiety, or substance use disorders, experience impacts on their ability to manage their life effectively and thus result in HRSN. The Path Assist program may provide resources for disease management, access to healthcare services, information on available treatment options, and referrals to support groups, including primary care doctors or specialized healthcare providers.

To target the population with high levels of HRSN for outreach and prioritization and to increase the efficiency of CHN, Path Assist utilizes rules-based and predictive AI/machine learning models empowered by clinical and social data. By leveraging data analysis and predictive modeling techniques, the program identifies individuals who are most likely to benefit from the services and support offered by Path Assist.

Here's how the rule-based and predictive Artificial intelligence (AI)/machine learning model can be used in targeting the HRSN population:

Data Collection: Path Assist gathers relevant clinical and social data from various sources, such as healthcare providers, social service agencies, government databases, and surveys. This data may include information about demographics, health conditions, socioeconomic factors, access to resources, and utilization patterns.

Data Analysis: The collected data is analyzed using rules and algorithms to identify patterns, correlations, and risk factors associated with HRSN. The model examines various factors contributing to high HRSN levels, such as chronic diseases, disability status, socioeconomic disadvantage, mental health conditions, and substance use issues.

Predictive Modeling: The model utilizes the analyzed data to develop predictive models that identify individuals at high risk of experiencing HRSN. These models consider various variables and risk factors to estimate the likelihood of an individual requiring assistance and support in housing, transportation, food, employment, and healthcare.

Outreach Prioritization: Based on the rules and predictions generated by the model, the Path Assist team prioritizes its outreach efforts and allocates CHN resources more efficiently. For example, individuals with a high probability of experiencing HRSN may be targeted for proactive outreach and offered tailored support services to address their needs.

It's important to note that while predictive models can provide valuable insights and improve outreach prioritization, human judgment and discretion remain crucial in the decision-making process. The models will be regularly updated, validated, and combined with the expertise of healthcare professionals, social service providers, and CHNs to ensure effective and ethical use of the data for supporting the HRSN population.

In addition to targeting the high-utilization population with significant HRSN, Path Assist addresses the importance of providing assistance and resources to individuals who may have lower levels of HRSN but still require support. By including a portion of the low-tier HRSN population, the program ensures that a broader range of individuals can benefit from the program's resources and services. This inclusive approach ensures that individuals receive support early on and have access to the resources required to maintain their well-being and prevent their situation from deteriorating further.

We hear from Medicaid and MCO leadership that while many networks and community efforts exist, there is little activity to facilitate networks, engagement, and community connection. In response to that stated need for facilitation and in partnership with trusted providers of social care and health care (Community-Based Organizations, local health departments, Federally Qualified Health Centers, and other government entities), Activate Care deploys its CHN workforce distributed throughout/within the local community organizations. We provide the administrative infrastructure, technology, and quality oversight of the CHN workforce that community partners will directly employ.

Our program aims to create a local CHN workforce that will implement an evidence-based CHN intervention while assuring high fidelity to that intervention. This transformational, preventative model of care can help address these monumental health equity challenges and meet the needs of the plans contracted to manage the underserved and rising risk populations.