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By Scott Dillingham

The integration of Social Determinants of Health (SDOH) and community-based services into Medicare Advantage and Special Needs Plans (SNP) is expanding and vital to addressing the needs of the most vulnerable within those populations.


Quality measures such as HEDIS and Star Ratings are highly sensitive to the impacts of these types of initiatives, highlighting the need for seamless collaboration between healthcare providers and community-based organizations (CBOs) as well as providing a financial incentive. 


Efforts to enhance these ratings require a comprehensive approach that addresses the unique needs of each member, particularly regarding SDOH. And that individual member experience has direct and meaningful impact on how the sponsor programs are scored or ranked.


CBOs play a crucial role in this as a partner, they are deeply rooted in local communities and possess valuable insights into the social and environmental factors affecting member health – often having relationships with those in need that span years or even decades and likely crossing beyond what might have been a “single thread” referral.


By integrating CBOs into a digitized care and service delivery ecosystem, healthcare providers can leverage their expertise to deliver tailored interventions and support services.


This integration must include data sharing, insights generation, and care coordination, ultimately maximizing the impact of interventions aimed at improving both health outcomes and member experience.


In addition to addressing immediate healthcare needs, this collaborative approach enables proactive intervention strategies.


By analyzing data trends and patterns within communities, healthcare organizations can identify potential health risks and implement preventive measures, reducing the likelihood of costly hospitalizations, emergency room visits or even medication adherence “slippage”


The integration of these new partners into the healthcare ecosystem represents a paradigm shift in how healthcare organizations approach SDOH and community-based services within Medicare Advantage and SNP plans.


By leveraging the strengths of CBOs and harnessing the power of collaboration and data, healthcare providers can achieve meaningful improvements in member health and elevate performance metrics like HEDIS and Star Ratings

Maximizing HEDIS and Star Ratings Through CBO Collaboration

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