socially determined corporate overview

SOCIALLY DETERM IN ED

Socially Determined Corporate Overview Social Determinants of Health –

From Analytics to Action

September 2018

SOCIALLYDETERMINED

Socially Determined’s Significant Seven

ECONOMIC WELLBEING

How income, employment, access to benefits

and financial security affect health and health

care

HOUSING

How the characteristics of dwellings within an

area affects the health and healthcare of the

people living there

TRANSPORTATION

How the availability, accessibility and safety of

transportation in a neighborhood affects health

and health care

FOOD INSECURITY

How being without reliable access to a

sufficient quantity of affordable, nutritious

food affects health and health care

+

CRIME & VIOLENCE

How the prevalence of crime, violence and

legal challenges in a neighborhood affects

health and healthcare

HEALTH LITERACY

How the ability to obtain, read, understand,

and use healthcare information to make

decisions and comply with treatment affects

health and health care

SOCIAL SUPPORT

How the availability of assistance from other

people and the feeling that one is part of a

supportive social network affect health and

health care

CONFIDENTIAL AND PROPRIETARY—DO NOT DISTRIBUTE 2

18

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Patient Journey

2 Screening & Assessment

• Utilizing data analysis to screen

patient

• Conduct secondary assessments

based on positive screens

• Identify specific subpopulations

Social Care Plan

• Identify key subpopulations

• Create social care plans and

referral strategies in clinical

context

• Catalog internal capabilities

• Create directory of community

services

3

4 Referral & Connection

• Educate patient on process and

personal role and support available

• Institute’s internal care

management

• Referral to external resources

• Share data and social care plan

5 Fulfillment & Tracking

• Track referral completion

• Measure outcome and

utilization measures

• Refine analytics based

upon ROI

• Iterate model based on

value based results

1 Data Collection & Analysis

• Collect and analyze SDOH data

• Collect clinical data and claims data

• Leverage commercial data

• Create a proactive process to target

specific patients based upon

analysis


SOCIALLYDET ERMINED

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Advanced data analytics to quantify/visualize risk factors

SD Analytics

Machine Learning

Pipeline

Principal Components Analysis

Clustering Algorithms

Inferential Networks

COMMUNITY

RISK

INDICES

SD Curated

Community Data

Clinical/claims data

from customer

COMMUNITY

VULNERABILITY

METRICS

SDOH INDICES

SDOH

POPULATIONS

SDOH

INTERVENTION

MODELS

SDOH

RISK

INDICES


ea lth Care Providers

Business

Social Services

Populations

0 All Med icaid

0 High ED Utilizer

0 NICU Moms

Median Income

Visible Area

$15,161

Cuyahoga County

$43,000

Ohio

~ 2,000

SOCIALLY D ET ERM INED

Avon Lake

Avon

North Rulgev1lle

Central Buckeye-Woodh Ill

Brooklyn Centre Hough

Kinsman Fairfax

St.Dair-Superior

Dark-Fulton Untversity

Mount Pleasant -

Wes tlake

ColumbooTwp

Highest Risk Neighborhoods

farrna

North Macedooa Royolon

Economic Scorecard

3 Risk Index

3 Viability Index

3 Growth Index

Twinsburg

500,000

'400,000

300,000

200,000

100,000

Search for Places

Chester Twp

Bonbndge Twp

Au rora

Risk Distribution

4

II

Auburn T

4.5

SocialScape™ Navigator Browsing consolidated social determinant data in communities


Client Case Study Cleveland Market

6

High concentrations of poor outcomes in 3 clusters

6 neighborhoods comprise half of total NICU babies

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SOCIALLYDETERMINED

Central

Clark-Fulton Stockyards

Brooklyn

Centre

Old

Brooklyn

Broadway-Slavic

Village


SOCIALLYDETERMINED

Neighborhood Risk Profiles & Prioritization

# Babies % NICU

Births

Avg. Cost

of Initial

Stay

Median

Income Economic

Index Food Index

Transportation

Index Housing

Index

All Medicaid

Pregnancies 5,027 14.6% $45,530 $41K 3.2 3.6 3.1 4.3

Neighborhood 1 348 15.2% $39,816 $30K 3.4 4.1 3.4 4.8

Neighborhood 2 162 17.3% $22,899 $30K 4.7 4.1 4.0 4.9

Neighborhood 3 324 16.0% $39,144 $41K 4.4 3.4 4.1 3.3

Neighborhood 4 263 14.4% $40,666 $34K 4.8 3.9 4.4 4.4

Neighborhood 5 231 12.1% $32,642 $30K 4.9 4.7 4.2 4.9

Neighborhood 6 393 16.0% $61,696 $19K 3.1 4.3 3.2 5.0

CONFIDENTIAL AND PROPRIETARY—DO NOT DISTRIBUTE 1 = best 5 = worst 8

High Risk Patient Archetype: Social & Clinical

Clinical Reality Social Challenges

Makes less than 1 in 4 have mental illness or $27,500 per year

85% do not have bank

accounts or credit

Low Educational

Attainment

40% Evicted at

least once

9 out of 10 are

unwed

substance abuse issues

Likely has one or more

conditions (diabetes,

hypertension)

complicating pregnancy

Typically will not

attend all pre-natal

appointments

Age 26-35, multiple

children

Social Independence

as the antidote

Has income greater

than $33,000

Level or positive

address trajectory

Attended

college

Has name on

housing lease

SOCIALLYDETERMINED CONFIDENTIAL AND PROPRIETARY—DO NOT DISTRIBUTE 9

Value Analysis—3 Year Financial Pro Forma

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RED CARPET

mom

SOCIALLYDET ERMINED

5 Neighborhoods 500 Moms 18 21 Months

Red Carpet for Mom Neighborhood Oriented Social & Clinical Intervention Campaign

SDOH

“Essentials”

Key Design

Food Prescription Transportation Stable Housing Integrated Behavioral

Program Health and Addiction

Services

Elements

Social Support Networking Technology Enabled

Center(s) – In-Person and Care Ecosystem

Virtual

Personalized

Wellness and Social

Care Plan

Self-Sufficiency

Programs to Drive

Sustainability


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SOCIALLYDETERMINED

2018-2019 Road Map 2018 2019

8 9 10 11 12 1 2 3 4 5 6 7 Beyond

CONFIDENTIAL AND PROPRIETARY—DO NOT DISTRIBUTE

Maternal

ER

Avoidance

MSSP

Pain

Activation Enrollment and Baseline Performance Year 1

Activation Enrollment and Baseline PY1

Activation Enrollment and Baseline PY1

Activation Enrollment and Baseline

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Analytics

Analytics

Analytics


Next 45 Day Work StreamsBegin the RFI process and explore partnerships with frontrunners

RFI/MOU Candidates

Food Transportation Mental/Behavioral Digital Care Platform

Grocery Vouchers

Prepared Meal Delivery

Meal Kit Delivery

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Campaign Activation Themes Analytics Program Management


The Social Care PlanAnalytics and the enrollment screening inform a personalized care plan for mom

Enrollment Screening Social Care Plan

Food Programs

Food Farmacy

SNAP Enrollment

Meal Delivery

Transportation

MetroHealth Van Program

Coordinated Lyft Rides

Transit Vouchers

Patient Advocate

Weight Management Plan

Centering Program

Housing Support

Pest/Mold Remediation

Respite Location Access

Lead Paint Abatement

Behavioral Health Services

Telemedicine Counseling

Provider-led Peer Group Program

Integrated Psychiatric Care

Home Visits (NF Partnership)

Diagnostic Testing/Vaccination

MFM Specialist Access

Clinical Care Component

5 Neighborhoods 500 Moms 21 Months

Target Neighborhood SocialScape Partner Procurement

Risk Profile & Intervention Match Social Funding & Matching


Social Investment & Partnership

RFI/MOU Candidates

Corporate Partners Foundations City/State Payers

Red Carpetv


SOCIALLYDETERMINED

MetroHealth

~ PROMEDlCA I WELL CONNECTED.

UPMC LIFE CHANGING MEDICINE

((,"Catholic 'JJHealth

Care Source·

fiiln PARAMOUNT

UPMC HEALTH PLAN

lndeP.endent 9 Health.

2018-2019 Active Partnerships Targeting regional partners with strong Payer/Provider Integration

Region Provider Plan Population Patient Focus # of Patients

Northeast Ohio 2018: Medicaid

2019: Medicare

Maternal Health

ED Utilization

Chronic Disease ~165K

Diabetes

Northwest Ohio All Patients ED Utilization ~640K Food Security

Pediatrics

Western PA All Patients Breast Cancer ~700k Transportation

Cardiology

Western NY All Patients Metabolic/Obesity

Bariatric ~400k Maternal Health

5 Regions All Seniors Social Isolation ~1.5M


SOCIALLY DETERM IN ED

WE ARE

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socially determined corporate overview

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