Personalized Approaches to Solving Social Needs

Nearly half of adults in the US face at least one unmet social need — and overcoming those challenges requires tailored, person-centered approaches. In a powerful and insightful webinar, presented in partnership with Fierce Healthcare, Abner Mason, Chief Strategy and Transformation Officer, and Meredith Welsh, SVP of Operations and Head of Service Delivery at GroundGame.Health, explored engagement strategies to identify and solve social needs at scale in a way that’s personal, effective, and sustainable.

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You can’t achieve health without addressing social needs

The central theme of the discussion was clear: if we want better health outcomes, we must address social challenges like food insecurity, housing instability, transportation barriers, and financial stress. Meredith shared that these are not fringe issues — they impact over 60% of the members GroundGame.Health has engaged, across all lines of business including Medicaid, Medicare, commercial plans, and exchanges. And on average, these individuals had 3.4 needs each.

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Barriers to addressing social needs

Despite growing awareness, Abner and Meredith shared different examples of the major gaps in how the healthcare industry addresses the following issues:

• Siloed systems: Clinical care and social care have traditionally operated in isolation and often don’t know how to connect members with trusted, effective community-based resources.

• Limited resources: Even when resources exist, simply offering a food pantry address to a member doesn’t help if it’s closed that day, or if it doesn’t serve someone with specific dietary needs.

• The self-serve gap: Some people can self-navigate with a referral link, but others, like Lisa (profiled during the webinar; view her story here), need intensive, human-to-human support.  

• Closing the loop: It’s difficult to confirm whether a referral was acted upon or whether the need was actually resolved.

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The personalized solution

Instead of asking health plans to become social care experts or forcing small community organizations to navigate the red tape of contracting with insurers, GroundGame.Health serves as a bridge. Meredith and Abner discussed how the approach combines technology, local partnerships, and a personal touch to bridge these gaps:

• Identification: Using referrals, claims data, and direct outreach, GroundGame.Health identifies individuals with social needs.

• Stratification: GroundGame.Health determines whether someone can self-serve or needs a higher level of support.

• Personalized support: Engagement is tailored — some receive texts or calls; others need boots-on-the-ground coordinators making home visits.

• Local CBO partnerships: GroundGame.Health contracts directly with trusted, on-the-ground organizations to deliver services to members.

• Sustainable funding: Through a high-trust technology platform, health plans fund services and GroundGame.Health routes those dollars to community partners, which creates a sustainable, scalable network.

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The results and ROI

Meredith shared a major health plan's independent analysis that proves the GroundGame.Health method works. Overall, there is a 5:1 ROI — for every $1 spent on addressing social needs, there was $5 in savings on medical spend. The analysis also included specific outcomes:

• 25% reduction in inpatient admissions

• 11% reduction in preventable ER visits

• 11% increase in overdue annual wellness visits completed

These figures underscore that addressing social needs isn’t just a moral imperative, it’s a financial one.

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A call to action

Abner and Meredith left health plans with a clear roadmap for implementing social need strategies within their organizations:

1. Identify which members have social needs (beyond assumptions).

2. Stratify by capability — who can self-serve, and who needs high-touch support?

3. Support each group with the appropriate resources and connections.

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Abner emphasized that this isn't just about being compassionate, it’s about being effective. Personalized, community-connected social care is essential to better health outcomes. As GroundGame.Health continues to scale its efforts across the country, this model offers a promising, proven framework for those ready to make solving social needs a strategic priority — not just a box to check.