Connecting Health With Life Beyond the Clinic

SDOH Coordination – Connecting Patients to the Support They Need

Healthcare is not a medical treatment. The Social Determinants of Health (SDOH) include the overall well-being of a patient through factors such as housing, food security, accessibility to transportation, and accessibility to community resources. When these needs aren’t met, clinical care alone isn’t enough. This is where our SDOH Coordination services come in to close this crucial gap by understanding patient obstacles. Linking them with trusted resources in the community and monitoring the outcomes of these solutions.

SDOH Coordination

Turning Social Challenges Into Measurable Health Improvements

94%

Food, housing, and transport screening patients indicate that they have better access to the necessary resources in 30 days.

89%

Fewer missed appointments as patients get transport and utility aid through coordinated activities.

96.7%

Users of our SDOH tools demonstrate greater quality scores in value care programs, increasing reimbursements and community trust.

82%

Of practices indicate a greater engagement of practices with patients when social needs are actively involved in relation to the medical care.

Social Determinants of Health: Smarter Coordination for Better Outcomes

Needs Assessment

We do food, housing, transport, and utility screening of our patients. Our evaluations uncover the background of challenges so that care providers have access to the data necessary to tackle social challenges in the initial phases, enhance care plans, and promote healthier and more stable lifestyles. Here is what we do:

  • Standardized screening for food insecurity, housing instability, transportation challenges, and utility access
  • Integration with EHR systems for documentation and care planning
  • Risk stratification tools to identify patients with urgent social vulnerabilities
  • Confidential, patient-centered assessments aligned with HIPAA and CMS guidelines

Resource Coordination

We network with partners, government programs, and local nongovernmental organizations quickly. Our system will provide patients with the resources they need at the right time, closing the most impactful gaps and minimizing provider workloads. As well as enhancing the community trust towards healthcare delivery systems.

  • Connect patients with community partners, government programs, and NGOs
  • Maintain updated directories of local and regional support services
  • Facilitate digital referrals to ensure patients reach resources quickly
  • Reduce hospital readmissions by addressing non-clinical health barriers

Reporting & Outcomes

We follow interventions and results so that you can quantify impact. Comprehensive dashboards enable providers to track compliance, identify success, risk, and present quantifiable patient and organizational performance changes.

  • Track interventions at the individual and population level
  • Generate compliance-ready reports for CMS and value-based care programs
  • Measure impact on patient health, including reduced ER visits and improved adherence
  • Provide dashboards that highlight ROI and social impact for your organization

Care Management What You Can Expect

At Care Management Solutions, we help providers address the social determinants of health (SDOH) that impact patient outcomes. Our process ensures your patients get the support they need, while your practice sees improved engagement and results.

Quick Discovery Caller
Quick Discovery Call

In just 15 minutes, we’ll learn about your patient population, current gaps, and coordination needs.

Onboarding & Workflow Setup
Onboarding & Workflow Setup

We integrate SDOH screening tools, resource databases, and referral workflows into your care process.

Go Live in 4–6 Weeks
Go Live in 4–6 Weeks

Your team will be equipped to identify patient needs and connect them with community resources quickly and effectively.

Continuous Optimization
Continuous Optimization

We monitor outcomes, refine workflows, and expand resource connections to keep your SDOH program impactful and sustainable.

An AI-powered, all-in-one solution that enables exceptional care

SDOH Service

Address the Social Determinants of Health (SDOH) that impact patient outcomes. Our solution identifies non-clinical barriers such as housing, food security, transportation, and social support, then connects patients to the right resources. With data-driven insights, you can improve health equity, reduce readmissions, and deliver truly whole-person care.

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Start your care management journey without any financial barriers. Fill out the form to discover how our care management solutions can help your team streamline care coordination, improve patient outcomes, and maximize reimbursement.