Population Stratification & Technology

Data is the language of healthcare, and more informed community risk analysis helps identify members needing assistance while providing continuous improvement in CHW operations. Using technology enables the coordination team to increase the number of members they serve daily.

Population Stratification

Our stratification process involves the curation of multiple person-level data sources, and the development of an
enhanced person profile which allows our care team to approach outreach from a risk-level approach.

A Data-Driven Approach

We use a data-driven approach, leveraging available and collected data to refine the program and report on community health. Health, demographic, community, and other consumer data predict each patient's social and health risk relative to the rest of the population. Our approach promotes identification of individuals who can benefit the most from our intervention model of proactive social care. 


Community Care Record

Tying the activities of CHWs to plan HEDIS measurements will help improve community operations and engagement. Professionals can leverage a custom community care record that integrates into existing workflow and technology infrastructure.

Our Community Care Record enables health plans to effectively close gaps and increase member engagement with a single longitudinal view into patients' care. 

• Identify health-related social needs (HRSN)
• Coordinate health and social services
• Refer members to trusted community-based resources
• Simplify administration and reporting


Ready to learn more?

Schedule a call with one of our experts to explore features, capabilities, and benefits tailored to your unique needs.