Case Study

AxisPoint for Social Determinants of Health


Identify and Address Social Determinants of Health

There is increasing resolve in healthcare to develop and deliver programs that remove barriers to care, specifically those arising from social determinants of health. With a growing number of initiatives emerging, it can be difficult to find a partner that understands the unique composition of the populations served. HGS works with clients to tailor our solution offerings to meet their needs, from delivering care coordination services and referring into an existing case management program, to local staff for highly vulnerable programs, to delivering our fully accredited case management program. We have proven success identifying and eliminating social barriers to compliance including transportation, food insecurity, housing, social isolation, behavioral and psychosocial issues.

Engage Complex, High-Risk Individuals

Individuals targeted for engagement receive notification via mail, text, email, or IVR prior to a care manager reaching out to them via telephone. For complex populations, our field staff have been able to find 75% of individuals deemed “unable to locate”.

Upon contact, we assess the health of individuals and identify barriers to care. Additionally, our skilled multi-disciplinary teams make appropriate customized referrals and escalations for individuals who may require additional services and support, such as behavioral health support, patient advocacy, or selecting a PCP.

HGS continues to check-in with individuals after initial contact and active management with a cadence of every 6 weeks to 3 months.

Analyze Continued Success

We understand the importance of being able to access your program data and ability to track reach rate and engagement. We grant access to a 24/7 online dashboard providing daily statistics plus exportable reports including information on escalations and referrals.

There is an increasing priority for healthcare organizations to understand the populations and individuals they serve. HGS is committed to providing outstanding care management services from completing HRAs to providing a comprehensive care management solution, AxisPoint, that leads to reduction in cost of care through driving engagement, outcomes, and results