Care coordination vendors addressing social determinants of health

March 22, 2020

Healthcare providers have always known that patients whose personal, social and financial needs aren’t met are less likely to be healthy and connected with their physicians. Not only do patients suffer, but the costs of caring for them are also higher and outcomes worse.

This isn’t a big surprise. After all, if a patient doesn’t have reliable transportation, they’ll probably find it hard to get to medical visits regularly. If they don’t have much community support in place, they’re more likely to get discouraged and stop taking care of themselves. If their housing is at risk, they might drop out of the care process entirely to focus on day-to-day survival.

In recent times, providers have begun to address these factors, called “social determinants of health” (SDOH), related to economic stability, healthcare access, education, and their community, neighborhood and build environments. To do so, they’re partnering with technology vendors that are solving some of the most stubborn SDOH-related obstacles patients face.

Signify Health

In the past, healthcare providers weren’t equipped to help patients tackle SDOH challenges effectively. After all, issues like food insecurity, housing problems or trouble getting rides to appointments are thorny problems that don’t come with easy answers.

Lately, though, health IT vendors are beginning to put SDOH information at their fingertips. One vendor giving doctors access is Signify Health, which manages a national network of 4,000 doctors and nurse practitioners serving more than one million Medicare Advantage members per year. 

Signify, which provides technology-based in-home care and complex care management services, uses a platform allowing it to collaborate with risk-bearing and community-based organizations to address patients’ SDOH concerns.

When visiting with patients in their homes, Signify clinicians make a point of identifying SDOH needs and capturing them in its technology platform in order to make case management referrals to the services patients need and manage patients’ SDOH needs as they evolve.

By identifying patients’ SDOH problems, Signify helps providers bring an extra dimension of support to patients which can help keep them well. Without the structure Signify’s technology offers, patients often get left behind.

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When patients don’t have access to reliable, affordable transportation, they’re far less likely to get the care they need. According to one study, about 3.6 million Americans missed or put off getting essential outpatient care because they had trouble getting to healthcare visits.

Offering patients rides to their medical visits isn’t a new idea. For some time now, Medicaid plans have given their members the option to book a ride with a taxi or ridesharing service at no cost to get to their appointments.

What’s new, however, is that vendors have begun to develop technology tools giving providers more control of the patient transportation process. One company offering such options is Roundtrip, which offers providers and support professionals – including care coordinators, social workers, nurses and others requesting rides—online tools designed to simplify the ride ordering process.

Roundtrip offers what it calls a “digital transportation marketplace” connecting patients with on-demand non-emergency medical transportation services such as rideshare options, medical sedans, wheelchair vans, and stretcher vehicles.

Patients and care coordinators use Roundtrip to book as many rides as they need, including both on-demand options or rides scheduled weeks or months in advance. Transportation providers can then view the ride, claim the trip and give patients an ETA. Roundtrip then sends patients text or voice reminders updating them on the ride status.

What ties a bow around all of this is that with Roundtrip managing all of the rides, providers get a comprehensive view of ride patterns which can help them predict future patient needs. 

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Patients are usually quite happy to take advantage of community resources, but in many cases, they don’t know how to find them without help. That’s what makes NowPow special. It’s not just a place helping consumers hook up with social workers, it’s a platform helping patients “self-prescribe” the community resources and supports that meet their needs.

NowPow supports about 22,000 care professionals serving more than 7 million people, and its resources can be found in 14 states as well as the District of Columbia.

The company (whose name is short for “Knowledge is Power”) offers users a single place to find referrals to care and help they need. The platform shares the information, tracks its use and coordinates referrals that address patient needs.

Adding value to its services, the resource information it gathers is “hyperlocal,” meaning that it takes community nuances into account when gathering resource data. This includes not only social service community options but also includes details about restrictions, consumer eligibility, required documents, and languages spoken.

On the back end, NowPow is designed to connect the resource information with providers’ EHRs. The intent is to make it easier for providers to integrate the information into their EHR workflows. 

The platform also includes an analytics engine that helps to measure how the referral processes working and what outcomes result from resource referrals.

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As the healthcare industry moves forward, it’s critical that factoring in social determinants of health becomes a central part of managing and delivering care. In the meantime, companies like Signify, Roundtrip, and NowPow are laying the tracks that others can follow.


Redox makes it easy for digital health solutions addressing SDOH to integrate with any EHR in a scalable, quick to deploy way. Learn more about how these incredible organizations integrate with EHRs using Redox.

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