Supporting high-acuity individuals by addressing social needs

GroundGame.Health, in partnership with FierceHealthcare, hosted an insightful sebinar titled, Bridging the Gap: Solving Health-Related Social Needs for High-Acuity Members. In this discussion, Abner Mason, chief strategy and transformation officer, and Meredith Welsh, senior vice president, operations and head of service delivery, explored innovative strategies for supporting high-acuity individuals by addressing social needs, with a focus on underserved communities. Through real-life cases, challenges, and strategic insights, they highlighted how meeting health-related social needs is crucial to delivering holistic healthcare that goes beyond clinical care alone. GroundGame.Health remains committed to making meaningful, community-level change a reality by solving social needs at scale.

‍

For many individuals, especially high-acuity members, health challenges are deeply intertwined with unmet social needs. These include financial strain, lack of transportation, food insecurity, inadequate housing, and more. Abner kicked off this discussion by emphasizing that addressing these needs is critical for holistic care, especially since they impact people across all demographics, regardless of healthcare coverage type. In fact, 46% of all US consumers have at least one unmet health-related social need (HRSN).

‍

Abner explained that one of the key challenges is identifying these social and economic needs due to the siloed framework between healthcare and social services. Identifying these needs requires innovative methods, and Abner emphasized the need for a tailored, local approach to identify and address these social needs, rather than a one-size-fits-all model. This is especially true for high-acuity members who may be dealing with complex conditions, making them less likely to engage in self-advocacy.

‍

Understanding the Unique Needs of High-Acuity Members

Lisa’s story serves as a powerful example of the real-world impact of a human-to-human approach. After undergoing major heart surgery, Lisa returned to a home in rural Louisiana that posed several health hazards due to hoarding and other issues, making it impossible for in-home health services to enter and assist her safely. In this instance, a GroundGame.Health Care Coordinator, Melissa, took a personalized approach, assessing the situation and leveraging local resources.

‍

Melissa identified a group of social work students who were able to help clean and reorganize Lisa’s home, removing six dumpsters’ worth of debris. The cleanup transformed Lisa’s home into a safe environment, allowing in-home care services to step in. As a result, Lisa could finally receive the medical and daily living support she needed, which significantly improved her quality of life and overall health. This story underscores the difference that a local, human-to-human connection can make, especially for high-acuity individuals who are overwhelmed and unable to self-serve.

‍

This story also highlighted the need for tailored approaches that go beyond high-tech solutions. While technology can streamline processes and support self-service, individuals like Lisa may be too overwhelmed to navigate such solutions without hands-on assistance. There is a clear contrast between tech-driven solutions, which can be effective for certain populations, and the human connection required to aid high-acuity members in complex situations.

‍

Meredith emphasized that Care Coordinators, like Melissa, build relationships and trust with members, which can lead to a transformative impact. Trust enables Care Coordinators to understand and address the real needs of individuals, while also reducing the stigma that may prevent individuals from seeking help. Abner also discussed the importance of having local knowledge, as Care Coordinators with community ties can connect members to appropriate resources like food pantries, faith-based organizations, or other local support systems.

‍

Addressing vs. Solving HRSNs

The audience was asked the following poll question: What is the biggest challenge your organization faces in solving health-related social needs (HRSNs)? The results are below.

‍

• #1 Answer: Engaging hard-to-reach individuals
• #2 Answer: Limited/no access to local resources
• #3 Answer (Tied): Identifying members with social needs & Measuring impact
• #4 Answer: Communication challenges
• #5 Answer: Confirming/documenting social need closure

‍

These poll results underline the importance of personalized engagement and local partnerships to effectively reach and support those in need. Abner and Meredith further discussed the distinction between addressing and solving HRSNs. They emphasized that merely addressing a need, such as directing someone to a food pantry, is often insufficient, as it provides only temporary relief. A transformational approach, in contrast, focuses on solving needs in a sustainable way by helping individuals gain access to long-term resources, such as enrollment in food assistance programs like WIC or SNAP.

‍

Meredith provided insights into the importance of community-based organizations (CBOs) in building a trustworthy support network. CBOs often have deep roots in the community, which can help them reach populations that are otherwise difficult to engage. Many high-acuity members face multiple barriers, including financial or housing insecurity, making it essential to have a wide-ranging network of CBOs and resources available. However, CBOs encounter many challenges when working with health plans, so they are often under-resourced, even though they are instrumental in delivering tailored support for complex social needs. GroundGame.Health offers a unique model that increases financial capacity within communities to sustain social care delivery, making it easier for health plans and CBOs to fulfill their shared goal of closing the loop on HRSNs and gaps in care.

‍

Scaling Up and Sustaining Impact

To truly address HRSNs on a large scale, Abner and Meredith emphasized the need to balance operational efficiency with maintaining high-quality, personalized support for high-acuity individuals. Sustainability requires a fully integrated approach that combines both clinical and social services. While technology can enhance certain processes, Abner noted it cannot replace the complex, human-centered support essential for addressing these needs. GroundGame.Health employs a scalable, hyperlocal model powered by its advanced technology platform and national network of CBOs.

Meredith highlighted GroundGame.Health’s remarkable outcomes for 2024:

‍

• Processed over 600,000 referrals for high-need individuals
• Solved more than 165,000 social needs
• Infused over $17 million back into communities

‍

These metrics reflect the impact GroundGame.Health has had in creating a scalable, strategic network rooted in local partnerships. Through collaboration with CBOs, GroundGame.Health facilitates personalized, culturally tailored interactions that offer real, human-to-human support, making a meaningful difference in people’s lives.

‍

Abner and Meredith underscored the ongoing need for innovation and closer alignment between healthcare and social services to advance health equity. Addressing social needs for high-acuity individuals is essential for delivering truly equitable healthcare. By integrating clinical and social support, GroundGame.Health aims to provide solutions that go beyond surface-level assistance to create long-term health improvements and transform lives.