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.

The COVID-19 pandemic shined a spotlight on the urgent need to modernize the nation’s public health system. Despite success in rapidly developing vaccines, the unprecedented public health emergency also exposed significant gaps in U.S. public health infectious disease data collection and analysis methods which are critical for identifying behavioral risk factors and preventive actions.

The Problem

Unfortunately, inefficiency remains a hallmark of the U.S. public health surveillance system due to the following two lingering issues:

• Disparate data collection systems

The CDC receives data from all 50 states and more than 3,000 local jurisdictions and territories. Hospitals, providers, and laboratories use a variety of systems to collect this data which is then reported to state, city, and local public health agencies. The information is then shared with CDC and other federal agencies. In general, each city, county, and state decide what information is collected, as well as how and when it can be shared with CDC.

What’s more, many current systems rely on disease-specific monitoring and manual data entry, which substantially burdens federal data partners. State and local reports to CDC are often delayed because the systems and data are simply not interoperable.

• Antiquated data-sharing methods

While data is increasingly shared via automated, electronic exchanges, some data is still being sent by fax machines, excel spreadsheets, or even by phone. The CDC encourages standardization, but it lacks the authority to receive data directly without establishing a data use agreement with each state and local jurisdiction. 

As a result, the agency must manually clean the data before conducting the analyses needed to provide an aggregated picture of public health. It can take weeks or even months to share the data with public health authorities, providers, and the scientific community,

The key challenge: how to collect and share information more efficiently so that information turns into actionable insights that can shape important public health decisions?

The Progress

The good news is CDC is leading multiple initiatives to make our public health infrastructure more connected and resilient. The CDC’s Data Modernization Initiative (DMI), launched in 2020, is a multi-year, billion-dollar-plus program to modernize core data monitoring and surveillance infrastructure across the public health ecosystem with the goal of enabling faster, actionable insights to support better decision-making. The recently created Office of Public Health Data, Surveillance and Technology will support this effort.  

Four key actions for fully modernizing the public health data infrastructure, and expanding data collection and sharing are:    

1. Adopt a Scalable, Federated Data Mesh Infrastructure

Today’s network of siloed, disease-specific systems creates significant redundancies and inefficiencies. It cannot scale to support the level of data aggregation, access, and speed public health agencies need. 

A scalable, federated data mesh infrastructure would allow federal agencies to curate high volumes of rich, interoperable data across their ecosystems. They could then accelerate their aggregation and analysis, and in turn, their public warnings and outreach, which are critical for fast-moving threats such as infectious diseases. 

By decentralizing data repositories, a data mesh allows those who are most knowledgeable about their data to control it, namely the public health entities functioning as nodes in a network. Via the mesh, the CDC would engage with electronic health records (EHRs), lab reports, genomic sequencing information, immunization, and other records. State and local agencies would then similarly engage. With CDC defining mesh policies and managing the mesh, data can be ingested, cleaned, standardized, and provisioned for use. 

With such a decentralized information technology architecture, federal agencies could also integrate technology to facilitate HIPAA-compliant patient record matching. This could be achieved without creating bottlenecks typically associated with centralized reporting and dissemination. 

Powered by robust metadata, search features and a centralized data catalog, the mesh would enable authorized personnel to effectively find, access, aggregate, and analyze public health data. This information could also be merged to support the principal guidelines for sharing and managing data adopted by research institutions worldwide, known as the FAIR Principles (Findable, Accessible, Interoperable and Reusable).

2. Protect Privacy 

Protecting the confidentiality of patient health information must be a top priority when modernizing public health infrastructure. The data mesh described above can integrate privacy-preserving record linkage (PPRL) technology which allows for data to be linked across different data sets without exposing individuals’ personal information.

PPRL technology maintains HIPAA compliance while enabling the matching of identifiable patient data without compromising patient privacy and confidentiality. For example, PPRL employs hashing to convert variables such as names, birthdates, and addresses into encrypted tokens that preserve the original values.

Linking data at the patient level enables a comprehensive view of an individual’s health, allowing researchers to answer questions that would otherwise require extensive primary data collection or complex data use agreements.

By integrating PPRL with standardized Fast Healthcare Interoperability Resources (FHIR) data components, public health agencies would be able to ingest and collect data from multiple sources and feed it into scalable analytics and modeling tools.      

3. Expand Data Sources

Currently, limited  EHR and social determinants of health data (such as access to transportation, rates of chronic disease, food insecurity, and crime) are interoperable via the established standard – the United States Core Data for Interoperability (USCDI). This data should be augmented by structured health data which is currently siloed in other agency systems including:

• Geospatial data such as walkability and access to care
• Remote-sensing data, such as wastewater testing and satellite imagery
• Mobility data from smartphones, GPS, and sensors along highways 

By layering additional data from siloed health systems and non-health sources, public health agencies could enrich the baseline USCDI data to gain deep insights. Recent efforts demonstrate the value of multilayered data to track the spread of COVID-19 in wastewater samples across the country, understand the impact of social distancing during the pandemic, and predict obesity rates.     

While encouraging, however, these results are limited in scope. Real-time, actionable surveillance at scale is impossible because of the lack of interoperability across data sources. Alternate approaches that bring more data into public health models and simulations must be pursued.

By extending interoperability and connecting the universe of rich, relevant data, public health agencies could boost the accuracy of prevalence estimates, counter-balance biases in traditional data collection, effectively target control and prevention strategies, and better allocate resources.

4. Harness Intelligent Automation 

Modernizing surveillance systems without burdening the public health workforce is a major challenge.

Public health agencies at all levels face a dire shortage of workers, with roughly 44 percent considering leaving their jobs within the next five years. That’s why public health agencies should adopt intelligent automation tools.

Intelligent automation can significantly improve infectious disease reporting by automating the collection and transfer of relevant health information from EHRs. When a health worker records a particular symptom or disease case in a patient’s EHR, the system could automatically send the data directly to CDC, eliminating current administrative reporting burdens. Improvements in the EHR aren’t limited to public health use – intelligent automation systems can also enhance the care provided to patients and decision support provided to providers.

Intelligent automation systems could also scan and interpret lab reports and clinical notes to uncover disease cases that might otherwise elude health officials, and trigger reports to state and local authorities. Additionally, technology learns and adapts. Powered by artificial intelligence and machine learning, these systems can go beyond simple optical character recognition by leveraging natural language processing to understand context, reduce noise, and improve accuracy.

Conclusion   

With a more modernized data infrastructure, public health leaders will be better equipped to identify and contain outbreaks, understand disease burdens, guide policy changes, evaluate and improve prevention and control strategies, and target research investments. The bottom line: enhanced data collection and analysis capabilities are critical to improving our nation’s public health outcomes.

About Kenyon Crowley

Kenyon Crowley, PhD is the Health Analytics Lead for Accenture Federal Services. Dr. Crowley brings nearly twenty years of health information technology expertise to his role. In his role at Accenture Federal Services, Dr. Crowley will help to accelerate the responsible and ethical use of AI and other advanced analytics tools across the federal health sector to help improve the well-being of all people in the country.

As the healthcare industry continues to evolve, there is a growing need for innovative solutions that not only improve the quality of care but also make care more accessible. Non-emergency medical transportation (NEMT) plays a crucial role in helping patients get to where care is delivered. As healthcare reform efforts continue to gain momentum, transportation benefits have become an increasingly critical component of providing equitable care to patients. NEMT helps close the health equity gap by ensuring all patients can access care, regardless of their location, medical needs or transportation options.

In recent years, technology has played a significant role in the advancement of the NEMT industry. Modern NEMT solutions streamline the ride booking and scheduling process, introduce new modalities, improve the overall experience for patients, and decrease fraud, waste and abuse (FWA). For decades, the industry lacked a patient-centric approach focused on efficiency, reliability, and accessibility for all populations, especially those enrolled in Medicare Advantage and Medicaid plans.

A reliable NEMT program can help health plans reduce administrative burden, lower the number of missed appointments, and ensure that patients receive the right level of care and support at the right time during their healthcare journey. Using integration services, health plans can integrate NEMT solutions and programs directly into existing platforms to better manage the member experience and provide an extra layer of connection for members when they utilize these benefits.  

By collaborating with innovative NEMT partners, health plans have made great strides to enhance the overall member experience. Historically, the member journey was largely overlooked, limiting members to two-day-plus advanced notice or long wait times for rides. With the introduction of on-demand ride-booking services through rideshare partners like Uber and Lyft, member needs are prioritized and personalized. Patients can book a ride when and where they need it; then, plans receive real-time updates and notifications during a member’s ride and can make any necessary adjustments as needed. Real-time ride monitoring helps reduce stress and anxiety for patients, prevents FWA, and ensures every ride has a digital record complete with geolocation at every step of the journey.  

While technology-first NEMT has advanced rapidly over the past few years, we’ve only begun to scratch the surface of how it can revolutionize care accessibility. As Medicare Advantage and Medicaid plans continue to grow, NEMT partners will play an increasingly important role in scaling transportation benefits. By working with healthcare providers and payers to integrate NEMT benefits into existing programs and systems, we can provide high-quality transportation services to our most vulnerable populations.

Given the proximity to high-acuity and underserved patients, who are commonly enrolled in Medicare Advantage and Medicaid plans, it’s important to determine whether a transportation provider has the capacity and expertise to meet the individual needs of each member. In a recent study, 21% of U.S. adults without access to a vehicle or public transportation skipped needed medical care last year. This experience is shown to vary depending on other factors such as race and ethnicity, household income, urban or rural location, disability status, and more. Expanding ride modalities with options like on-demand rides provides members the flexibility and comfort they’re looking for in an increasingly-consumer driven healthcare environment as well as plans with the tools they need to close these health equity gaps in accessing care for a diverse population. 

By offering members benefits that work for them and their unique needs, plans can focus on increasing benefit utilization and improving critical present and future Stars Ratings benchmarks like member experience and health equity. When measuring a program’s effectiveness, vendors and plans must work together to decide which data to capture, determine what’s working, and identify areas for improvement. Technology-first NEMT plays a critical role in capturing data and turning it into metrics that matter. 

Despite great strides made to help address the social determinants of health (SDoH), such as transportation access, government regulations continue to play a critical role in shaping the industry’s growth and impact. Various regulations, such as the Medicaid Non-Emergency Medical Transportation Benefit and the Americans with Disabilities Act, have positively impacted how patients access care and the quality of transportation services provided by NEMT vendors. These regulations are crucial for individuals who may not have reliable transportation options, especially those living in rural or low-income areas, and help ensure NEMT providers meet specific quality standards and are held accountable for providing safe and dependable transportation services. As the NEMT industry continues to evolve, it is important for providers to stay informed about the latest regulations and to work closely with government agencies to ensure they are providing the highest quality transportation services possible. By doing so, they can help close the healthcare equity gap and ensure all patients have access to the care they need.

While we can’t predict all the roadblocks the healthcare industry will face in the future, it’s clear that a more efficient, reliable and cost-effective NEMT solution will continue to drive better outcomes for health plans and patients. 

About Andy Auerbach

Andy Auerbach is the Chief Revenue Officer of SafeRide Health, the leading technology-first platform connecting patients to care one ride at a time.

What You Should Know:

• Innovaccer Inc. announced that Emcara Health, PopHealthCare’s national value-based medical group that delivers advanced in-home primary care for seniors and vulnerable populations, has selected Innovaccer’s Best in KLAS data platform to accelerate its ability to drive growth and rapidly scale Emcara Health’s integrated care solution to more communities nationwide.
• The Innovaccer data platform will enhance Emcara Health’s ability to create unified patient records that provide a 360-degree holistic view of patients by integrating data from myriad EHRs, HIT systems, and third-party community data (such as SDoH). Interoperable, EHR-agnostic physician engagement will further providers’ efforts to close coding and care gaps at the point of care and make informed decisions that drive better clinical outcomes. 
• Data-driven, customizable TCM protocols will help ensure effective care coordination with automated transitional and chronic care management for at-risk and rising-risk populations.

What You Should Know:

• The U.S. Department of Veterans Affairs (VA) and The Rockefeller Foundation are teaming up to expand Food is Medicine programs, from medically tailored meals to produce prescription programs, at key VA health care facilities across the country.
• VA and The Rockefeller Foundation will support two Produce Prescription pilot projects and associated research pilot programs at VA health care systems in Salt Lake City, Utah and Houston, Texas, with the goal of improving the quality of life for Veterans living with or at-risk of diet-related health conditions. 
• The Produce Prescription program pilots will provide eligible Veterans the opportunity to enroll in the Fresh Connect program to receive $100 per month for fresh produce and receive nutrition education and ongoing coaching from VA registered dietitian nutritionists.

Increase Healthy Food Access, Health Outcomes for Veterans

VA is the largest integrated health care system in the United States providing care at more than 1,200 health care facilities to over nine million Veterans. Unfortunately, about 27% of Afghanistan and Iraq war Veterans experience food insecurity — a rate more than double that of the general U.S. population. Studies have found that Veterans, particularly those with food insecurity, are also at greater risk for diet-related diseases. One study reported 86% were overweight or obese at their first visit to a Veterans Health Administration (VHA) clinician, while another showed the prevalence of diabetes is at least 5% higher among U.S. Veterans than the general population. Expanding Food is Medicine programs at VA will address the impact of diet-related disease and food insecurity among Veterans, while evaluating their impact for building the case to embed these programs into a fully integrated health care delivery system.

Expanding Food is Medicine Programs with Grants

The partnership will focus on expanding the implementation and evaluation of Food is Medicine programs throughout VA’s health care system, and support from The Rockefeller Foundation will provide grants to organizations such as About Fresh, a Boston-based non-profit, that will help enroll Veterans in produce prescription pilot programs at VHA facilities in Salt Lake City, Utah and Houston, Texas. Designed in collaboration with VA clinicians, staff and the VA’s Office of Food Security, these projects will build upon the groundbreaking work led by Reinvestment Partners to increase Veteran enrollment in their EatWell program with the VA facility in Durham, North Carolina.

Researchers at the University of Utah will evaluate the projects’ impacts on health, health care costs and utilization and participant satisfaction. Lessons and data garnered through these pilot projects will help to inform the development of more impactful policies and program design to scale the reach of Food is Medicine as a benefit for Veterans across the VA health care system.