Social Integration

Contributing expert: Melissa Sherry

Making sure a person's social needs are met plays a critical role not only in their quality of life but also their whole health. In fact, research shows that 80% of what drives a person's health takes place outside the doctor's office.¹

While healthcare stakeholders recognize the importance of social factors in cost and quality of care, the industry is still working on integrating those factors into operations. At Elevance Health, we're leveraging data-driven insights and community partners to address consumers' social needs, with the goal of making healthcare more personal, equitable, and holistic.

Using Data to Drive Equitable Care

Watch this video to learn more about how we're addressing social drivers of health.

We have an opportunity to make healthcare more personalized and equitable — to help people live healthier, more enjoyable lives. We all deserve to be healthy, with the right care and resources.

At the intersection of humanity and technology, we can positively impact the lives of everyone we touch by considering the whole health of the person, and the physical, behavioral, and social factors that impact them.

Social drivers of health — access to food, transportation, and shelter — have a massive impact on a person's overall well-being. At Elevance Health, we use our vast data resources and the power of AI and analytics to identify the areas where those needs are the greatest. And we're taking action.

Armed with a more accurate picture of the factors surrounding members in our affiliated health plans, we begin to see parallels with their individual health and identify opportunities where more support is needed. Using digital tools, we can remove the obstacles to better health by meeting people where they are and partnering in our communities to connect them to the resources they need, breaking down the barriers to access quality, equitable care.

By collaborating within the health system with shared data driven insights and synthesized health records, we create a simplified experience, where healthcare consumers receive more proactive care management, cost transparency, and targeted engagement, and care providers are empowered with new sources of meaningful information that can revolutionize the provider-patient relationship.

At Elevance Health, we are connecting the care experience and improving health outcomes for those we serve — one zip code, one community, one individual at a time.

Inside Our Social Impact Model

Connecting consumers with the right care at the right time allows us to help care providers practice at the top of their licenses. Additionally, we can help reduce patient hospitalizations, improve outcomes, and boost consumer satisfaction.

That's where our Community Connected Care solution comes in. It leverages data and local community partnerships to proactively identify and outreach to individuals who may have health-related social needs, and connects them to community resources, driving better outcomes by reducing barriers to care. The solution was designed for payers to support consumers and care providers.

Community Connected Care includes:

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 prevalent social needs and stratify the population based on those needs.

Engagements

Designated pathways connect consumers and their families to social supports based on their needs. Partnerships with community-based organizations such as food pantries and area agencies on aging enhance our ability to meaningfully engage with consumers around their social needs.

Solutions

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

Quantifying Whole Health

One challenge the healthcare industry faces when it comes to improving whole health is subjectivity. The industry lacks a standard measure to quantify whole health.

We're working to change that with our Whole Health Index. It has been validated by the external research and data analytics consultancy firm Mathematica, which found positive correlations between the Whole Health Index and several health outcomes. In 2023, those findings were touted in the NEJM Catalyst publication.²

Unlike other measurement tools, the index goes beyond using self-reported details. Instead, it looks at claims and social information. It uses patient- and population-level data from 93 measures representing physical, behavioral, and social factors. That information generates a single score for each consumer to indicate the state of their whole health.

We've calculated Whole Health Index scores for more than 45 million consumers of our affiliated health plans across all business lines, including Medicare, Medicaid, dual-eligible, and Commercial.³

Improving Whole Health

The Whole Health Index creates measurable data that allows us to take action to help consumers with low scores. That's the impetus for our Whole Health Improvement Now (WIN) program.

It identifies consumers in low Whole Health Index cohorts at highest risk for social needs and routes them to local community partners through our social care connections partner for a social needs assessment. Once assessments are completed, consumers are connected to social supports needed to address their health-related social needs. We work with care providers and community-based organizations to tailor outreach and programing to help those consumers with their health and social needs.

To date, WIN has:

Found 174,000 people in need of social support.⁴

Identified 2,000 social needs out of a 9,000-person cohort.⁴

Addressed 1,000+ of those social needs with follow-up services.⁵

1 U.S. Department of Health and Human Services. Community Health and Economic Prosperity: The Problem, the Causes, the Opportunities, and the Solutions—At a Glance (January 2021): https://hhs.gov/sites/default/files/chep-sgr-at-a-glance.pdf. 2 Winnie C. Chi, PhD, MS, J. Marc Overhage, MD, PhD, Todd Sponholtz, PhD, MPH, Binh T. Nguyen, PhD, Peter Brady, MBA, April Falconi, PhD, MPH, MA, Martha Johnson, PhD, et al.: The Whole Health Index: A Practical, Valid, and Reliable Tool to Measure Whole-Person Health and Manage Population Health. New England Journal of Medicine Catalyst (May 30, 2023): https://catalyst.nejm.org/doi/full/10.1056/CAT.23.0015. 3 Elevance Health, internal data (2023). 4 Elevance Health Pulse: How Our Whole Health Index Is Making an Impact (October 2023): pulse.elevancehealth.com. 5 Elevance Health, internal analysis (May 2023).

Download the Executive Summary of This Report

Executive Summary (PDF)