Building a high-tech, high-touch model to address social determinants of health
Early in my career, I served as a community health worker for Medicaid families in Baltimore, and that work raised some important questions about the disadvantages and health consequences facing people in low-income communities. In Baltimore, for example, the difference in life expectancy between people who live in low-income areas compared with those in more affluent neighborhoods can be as much as 20 years.
How could the life expectancies of people living just a few blocks apart be so vastly different — simply because of the neighborhood in which they live?
I saw time and time again how the environment in which the families lived contributed to higher rates of chronic disease and illness and impacted their ability to thrive. Although physicians generally recognize that social factors influence the health of their patients, many are unsure how they can intervene.
I wanted to better support these patients and the medical professionals who want to help them.
I met with families daily and tried to connect them as best I could to social services like food programs to address their unmet needs. But the information at hand was scattered and outdated, creating barriers to finding and connecting people to the right resources. We needed a better way.
Healthify was born from that experience. Our mission is to build a world where no one’s health is hindered by their need. By partnering with health systems, health insurance plans and relevant public sector organizations, we’re building the infrastructure that integrates social determinants of health into the health care ecosystem because we know that systematically addressing social determinants of health improves patients’ health and reduces the cost of their care.
Most of our partners recognize the importance of addressing social determinants as a powerful factor in a person’s health. In fact, it is now well known that factors including a patient’s income, race, gender, housing and education, among others, are responsible for driving as much as 60 percent of health outcomes.
Yet, health care organizations have difficulty connecting patients to the community services they need. And when they do, they don’t necessarily know whether the connection has been made and what the impact of the intervention was, due to fragmentation between health care professionals and social service providers. Healthify solves this problem.
We’ve developed a model that helps health plans and clinicians, who are paid partly based on how well they improve patients’ health, develop and maintain a coordinated network of community partners and introduce a better flow of information and work to address the social determinants of health. We start by identifying social and behavioral health care needs and then match patients to the best community services and resources available to them. Importantly, our software tracks and manages follow-ups to ensure connections—and progress—are being made.
In this way, we build bridges connecting community organizations, social services and government agencies with health care professionals and health insurers. For the patient, we’re creating end-to-end care that works to address social determinants of health.
The likelihood that a patient will successfully follow through when connected to a community resource is typically about 8 to 12 percent. With Healthify’s support, the success rate jumps to 70 percent. We’ve already trained more than 15,000 health care staff on Healthify’s model. And we’re connecting upwards of 100,000 people every 30 days to the supportive resources they need.
Similar models have seen reduced hospital admission rates, healthier patients and lower costs for the health care facilities that are treating them.
By partnering with community-based organizations, health systems and health plans are one step closer to ensuring that every individual and family within their communities have a better chance at a healthier life.
Healthify is funded in part by BlueCross BlueShield Venture Partners, L.P. , a corporate venture fund licensed by the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. The fund invests in promising emerging companies of strategic relevance to Blue Cross and Blue Shield Plans. These companies are bringing creative, cutting-edge solutions to the health care marketplace.
