Social determinants of health support expanding with GroundGame Health
- Identified social determinants of health needs including, but not limited to:
- Living environment
- Food insecurity issues
- Financial issues
- Social isolation, etc.
- Hospital readmissions
- A readmission risk score of more than 24
GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Empire, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.
A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.
The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.
To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email firstname.lastname@example.org.
October 2020 Empire Provider News