elevancehealth.com

Social Integration: Meeting Personalized Needs

Contributing expert: Pamme Lyons-Taylor, PhD

Everyone has social needs — the interactions and relationships we have with others is key to our quality of life. Those needs change over the course of a lifetime and the context of our lives.

For seniors, this could look like social isolation and depression following the death of a spouse or partner. For a person with a disability, this could look like the loss of affordable transportation when a bus route is changed, leading to concerns such as social isolation, loneliness, and depression. For a family with multiple needs, this could look like several things all at once.

Elevance Health understands the important connection between social and health factors, especially as needs change over time. A growing body of peer-reviewed research backs this up. A 2018 study published in Population Health Management showed a $2,443 net per-member decrease in healthcare spend when people had all of their social needs met through an integrated social care management model. Results from our own survey show similar findings. Among our affiliated Commercial and Medicare Advantage health plan consumers in select states, an additional social need was associated with a $1,000 increase in healthcare spending per year.*

* Internal data, 2022.

Our Approach

Our Community Connected Care Solution was created to leverage technology and data that is personalized to meet specific needs for better outcomes by synchronizing social care management with healthcare delivery. This solution was designed for payers — commercial, federal, state, or other — to support their consumers and their families along with care providers.

Using social risk data from the individual, population, and community levels, we can assess the breadth and depth of potential social interventions that can be offered based on a root-cause analysis. For example, our analysis might reveal a food desert coupled with high incidence of diabetes. Our intervention would be structured differently in that case than it would if the analysis revealed a wide area with a shortage of transportation, coupled with high incidence of diabetes. In either case, our goal would be to establish an intervention that removes the barrier created by the unmet health-related social need. Our solution is called Social Impact and includes three steps:

1) Data and Insights

Using insights from the Protocol for Responding to & Assessing Patients' Assets, Risks & Experiences (PRAPARE©) tool, our Whole Health Index, and other sources, we identify the most prevalent social needs and stratify the population based on those needs.

2) Engagements

We designate pathways to connect consumers and their families to related social supports based on the degree of need.

3) Solutions

We identify trends in social-need data to proactively create social interventions with targeted health outcomes.

Using this three-step process, we designed social interventions to help remove unmet social needs that have escalated to create barriers for our consumers to access and receive care.

Our Impact

Elevance Health's partnership with care providers extends to all aspects of healthcare delivery, and we see great potential in advancing whole health for our consumers in collaboration with our care provider partners.

It starts with data. It is essential to understand our consumers' key attributes, characteristics, and preferences, as well as their social well-being, to incorporate supports that help them meet their unmet health-related social needs before they become a barrier. This means creating new data sets that offer care providers insights on the prevalence of social factors in their patient panel.

Next, we need to find new ways to engage with our consumers and their families to validate their social needs at various points in time. A deep understanding of social needs, coupled with a record of their stated preferences, attributes, and characteristics helps us “keep all doors open” for consumers when social needs emerge. We offer multiple ways to connect: digitally, by phone or video, or face to face. This gives us the ability to connect with our consumers and their families in the way that makes the most sense for them.

Forward Together

We want to create partnerships with care providers to find better and stronger ways to define and evaluate quality. Most importantly, we want to create a system of care together that improves the overall health and vitality of our consumers, their families, and the community at large.

Healthcare is local and, therefore, the solutions must be framed to adapt for hyper-local needs founded on principles that are quantifiable and qualifiable. This is where whole health comes in — and this is what we do differently and how we want to work together with our care provider partners.