Community-Based Health Intervention™ (CBHI) addresses the socio-economic issues and social determinants that impact population health. CBHI is a proactive approach to claims prevention. Social determinants of health are driving up health care costs anywhere from 60-80%. If an individual cannot meet their basic needs for daily living, they are not able to focus on their health care needs.
This program provides feedback to providers and payers in a timely manner, facilitating effective communication and providing information previously unavailable to the healthcare provider.
The Community-Based Health Intervention™ provides:
Community-based visit by Licensed Nurse or Social Worker
Assessments for falls, depression, nutrition
Disease Specific Health Education
Social Determinants Review and Referrals
Advance Directives Education and State-approved forms
Weekly Touch point throughout 30-day intervention
Assurance of timely post-discharge follow-up with PCP when appropriate
Feedback to payers and providers
Supported by a HIPAA compliant, interoperable data platform