It can be hard to stay healthy without affordable food, housing, transportation to doctor’s appointments and other basic resources.
Social workers employed by Blue Cross and Blue Shield of Texas are trained to help members address these needs — generally known as social determinants of health, or SDOH. But the impact of their outreach depends on successfully engaging with members who are often difficult to identify and reach.
A team at BCBSTX turned to data science to craft an innovative solution to this challenge. They developed a predictive model to identify eligible members who are most likely to need assistance and respond to outreach.
“This is one of the first instances in which we are using artificial intelligence to identify members with SDOH needs who are likely to engage with social workers,” says Temi Adeyemo, lead data science product manager.
Adeyemo’s team created the model to enhance the impact of a pilot program targeting SDOH in certain employer-sponsored health plans — and make it possible to expand the program to more groups of members.
The data scientists first mapped the members in the pilot program to the highest-need census tracts in the Centers for Disease Control and Prevention’s Social Vulnerability Index. Next, they used several different sources of data, including data from previous interactions with BCBSTX social workers, to predict the members most likely to respond to outreach.
Since implementing the solution in April 2022, engagement rates increased nearly sixfold in Texas. This has the potential to make a powerful difference in people’s lives.
“We’re more targeted in our outreach now and we’re helping more people while also getting in touch with our most vulnerable members,” says Lauren McNamara, lead data scientist.
Social workers receive new SDOH referrals each month and attempt to connect with these members through phone calls, emails and other methods.
Members who choose to participate work with the social worker create a plan of care and establish health goals. The social worker also connects them with community resources to address SDOH needs such as affordable groceries, rental assistance and stress management.
“It’s understanding what’s going on with the members holistically, knowing what’s available to them under their benefit structure and then tailoring the resources to the member’s unique situation,” says Jo Christison, senior manager, clinical operations.
One member, for example, had been discharged from the hospital after a knee replacement without a wheelchair or a hospital bed for recovery. She didn’t understand the post-operation instructions and didn’t have transportation to her doctor’s office.
Shatara Johnson, a BCBSTX social worker, spoke with the medical facility that discharged her to clear up the problem, made sure the member got the equipment she needed and arranged transportation to follow-up visits.
“She could have missed her appointments without transportation,” Johnson added. “She was on short-term disability, so she needed those appointments to provide her job with documentation and receive proper payments. She was also a fall risk and could’ve ended up back in the hospital.”
A comprehensive assessment provides a holistic understanding of members’ potential needs, including ones that may be met by their health and wellness benefits.
“Employers also may offer a variety of programs to meet their employees’ needs, and members are not always aware of what those programs are,” Christison says.
Social workers are more fulfilled in their roles and members are often happy to know someone is looking out for them, Johnson says. “It’s about making members aware of the support that’s available and letting them know, ‘you may not need assistance now, but we are here to support you and advocate for you in the future, should a need arise.’”