Addressing the Social Determinants is a collective effort, we make it effective
A fully integrated automated periodic SDoH screening and Care Navigation platform
Care Interface automates periodic SDoH screening, orchestrates social needs-care management, and tracks outcomes to deliver results for Health Departments
The current mechanisms of screening SDoH and intervening are manual, episodic and lack a mechanism to scale cost effectively to reach a wider audience periodically. Our technology platform allows state health departments, county health departments, health systems, hospitals, Primary care clinics and Payer groups to automate some of the most important tasks and orchestrate with the right team member at the right time.
Care Managers team Increases Effectiveness with SDoH screening and collaboration AI platform
A veteran chronic care case manager for the Medicare Advantage Program at a health system in New York was overwhelmed. Everyday she would receive lists of people to call with never enough time to get to everyone. The existing rules-based system was no better than her assessment of age, number of chronic conditions and recent ED visits or hospital stays.
The health plan then implemented Care Interface, which gave her a prioritized list of patients to call, highlighted the clinical and social barriers increasing the risk for individual patients and provided recommendations for addressing those risks.
With the new system, she was quickly able to support and manage care for a woman who was at high risk for ER utilization over the next 3 months because she lived alone, lacked social support and had low technical fluency, CHF and diabetes. The case manager followed Care Interface's recommendations, enrolling the woman in a complex care management program. She was also able to secure her medication, which had run out, and an appointment and transportation to a local CHF clinic thereby avoiding another ED visit.