MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

Connect4Wellness (CFW) is a public–facing mobile app that allows users to identify and directly connect to community resources and agencies that address social determinants of health. This app is targeted to the growing number of individuals and families who struggle daily with socioeconomic and material hardships, including food and utility insecurity, housing deprivation and/or unemployment. The C4W app's objective are to: 1) engage users directly with resources for their personalized needs, 2) educate and guide users through the specific steps and tools involved in accessing resources, and to ultimately, 3) empower users to be informed and "activated" in addressing social determinants of health to achieve their best health.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Multiple reports have demonstrated that social determinants of health (including food insecurity, unstable housing, unemployment, and transportation barriers) are key drivers that prevent access to comprehensive preventive care. Currently, the majority of technologies designed to connect patients to community–based resources that address social determinants of health target healthcare institutions and require interface with health facilities to access these important platforms. Unfortunately, this restricts access for patients who are unable to access healthcare at all or do so infrequently due to barriers of cost, uninsurance and transport. Technologies that can be easily accessed by this population to address their hardships while simultaneously connecting them to healthcare are necessary to achieving health equity for the most underserved.

C4W users enter socio–demographic information, which will help to ensure that the services proposed are close to home, linguistically concordant, and culturally–sensitive. The user also enters information that will allow an assessment of current healthcare access and utilization (e.g. presence of insurance, insurance type, presence of a personal doctor, usual source for care, including emergency room and urgent care services; number of ER visits and/or hospitalizations in the last year). Responses indicating risk factors for suboptimal access to preventive care, including lack of health insurance, as well as signs of adverse healthcare utilization, will prompt immediate referrals to local primary care practices and insurance enrollment specialists. Once the sign–in process is complete, the app will administer a brief screening tool to assess the presence of a comprehensive array of socio–economic and material hardships, behavioral health, social isolation and intimate partner violence. C4W also facilitates user education through the availability of in–depth information about eligibility criteria for public benefit programs, instructions for filling out forms for social services, with available, fillable pdfs for real–time completion, and brief pop–up descriptions of how the selected material hardship negatively affects health. We believe that this purposeful user engagement coupled with interactive educational messaging will result in empowered healthcare users and communities.

The benefits of the C4W app are myriad: first, social service agencies and community based organizations can directly communicate with C4W users, without an intermediary facilitating communications. Second, health plans and health care institutions can access a rich source of data which for many organizations is not currently being collected, including limited English proficiency, health literacy, educational attainment and country of origin, in addition to robust information on healthcare access and utilization among individuals who may have costly, high–utilization patterns in emergency care, and suboptimal use of preventive primary care. Third, allowing users to access a public–facing platform 24 hours per day, 7 days per week, empowers them to locate services and service providers that may help meet very specific, unique needs, creating a more tailored approach to connecting to needed services and supports. C4W has the potential to produce a significant ROI for safety net hospital systems, by bringing a high volume of patients that are traditionally difficult to engage to primary care, mental health, and social service providers within their networks. Hospital systems can utilize C4W user data to identify patients at risk of suboptimal health and health care utilization outcomes, and create targeted approaches to reduce these risks. Similarly, State Medicaid and Medicaid Managed Care organizations who utilize C4W data will see a significant ROI as users who have successfully been connected to services and supports are more likely to avoid necessary, costly visits to the emergency room and hospital admissions, thereby lowering expenditures.

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