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Case Study

How CareAllies coordinates interventions to improve SDOH

10 Minute Read


    The challenge

    Social determinants of health (SDOH) have a major impact on people’s lives, including their well-being and quality of life—and differences in these factors across communities can contribute to wide health disparities. High poverty rates and inequitable distribution of resources in the Rio Grande Valley of Texas drew the attention of CareAllies and their independent physician association (IPA) client in the area—Valley Organized Physicians (VOP).

    The organization

    CareAllies, a subsidiary of Cigna, supports 66 provider organizations (over 455,000 lives) to help simplify and accelerate growth in value-based care with solutions that help engage providers; optimize value-based contracts with multiple payers; and improve performance, efficiency and patient care. Working with VOP, an IPA located in the Rio Grande Valley in South Texas, CareAllies launched a pilot to better connect VOP’s patients to social resources in their community.

    The approach

    To help identify VOP patients’ social needs and connect them to appropriate educational resources and community-based organizations (CBOs), VOP and CareAllies launched an SDOH pilot program. CareAllies created a Health Advocate Team – an interdisciplinary team that includes social workers, nurses, and a registered dietician who limit the burden placed on practices by addressing needs in the patient population on behalf of the patient’s primary care physician.

    The result

    In 2020, more than 1,300 social needs (e.g. food access, financial assistance, transportation needs) were identified by the team. Multiple attempts were made to connect with patients, allowing the team to engage with 85% of the patients. The Health Advocate Team was able to address 97% of identified SDOH needs. The team continues to raise awareness around SDOH and build relationships in the community to increase engagement while identifying more resources to make a difference in the lives of VOP patients.



    How CareAllies Approaches SDOH

    CareAllies recognized that in the Rio Grande Valley community, the most immediate problem in addressing SDOH needs wasn’t the lack of relevant social resources, but the ability to link patients with organizations and partners they would trust. Despite the availability of certain resources, it was clear that managing all of these connections would be an enormous burden to place on providers and practices alone.

    CareAllies’ SDOH partnership with VOP is successful for three main reasons. First, they utilize data and dedicated SDOH resources to support practices, avoiding additional burden. Second, the interdisciplinary team of Health Advocates has expertise, local knowledge and works closely with providers allowing them to identify and address SDOH needs in the best way possible. Third, the team follows through to close the loop and continuously reassesses processes to improve the program.

    • Reason

      Proactive and referral-driven outreach

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    • Reason

      Interdisciplinary care team

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    • Reason

      Tracking outcomes

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    How we know it’s working

    In 2020 CareAllies identitied more than 1,300 SDOH needs across VOP patients. The team was able to engage with 85% of the patients they reached out to and met 97% of the social needs of patients who were eligible and willing to participate.

    Early analysis of 2021 data showed fewer identified needs and lower engagement than the previous year; however, 98% of the needs were met for patients eligible and willing to participate. This raises the question – how should the success of an SDOH program be measured, and what can be learned by digging deeper?

    • Does a reduction in identified needs mean the program is working?
    • Does lower engagement indicate an increase in referrals for harder-to-reach patients?
    • How many referrals were for new patients vs. closed cases where new barriers arose?
    • Are there any trends that could help predict future SDOH needs?

    CareAllies plans to continue to analyze available data to help answer questions like these to help shape the future of the program. In the meantime, the team continues to build relationships in the community and partner with providers to improve patient care.


    Rate of successful engagement through outreach to patients


    Rate of social needs met for participating patients

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