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

  • Medication Inventory

  • Assessments for falls, depression, nutrition

  • Risk Stratification

  • 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