Technology is accelerating our ability to deliver effective care more efficiently. Technology and interoperability continue to combine social, behavioral and clinical data at the individual and population health level, enabling a more targeted, personalized approach to healthcare. Digital transformation has driven incredible scale in our industry, allowing us to apply new ideas to large communities and narrower intersectional cohorts.

Scale and impact, though, are not the same thing. Personalized and personal are very different.

True impact needs to be anchored by top tier technology. This is only part of the story. Impact is about humans helping humans, on the ground, leveraging lived experience, earning trust and solving individual challenges in the context of a culturally appropriate, personalized experience. 

Here’s one story that explains why.

Meet Barry*, a thirty-four year old father who has HIV. He lives with his two young daughters in California, where he is covered by commercial insurance. He works two jobs and is struggling to afford utility bills, healthy food for his family, and his HIV Baiketarvy medication.

Digital and AI can optimize the outreach to Barry. Technology can identify that a man living with HIV has financial insecurity and mental stress, and an automated tool can easily send him a list of social services he might want to follow up with. Technology has become very adept at surfacing data points and facilitating digital outreach. 

This is not the full picture though. For the full picture, we need to talk to Barry. 

It’s only when a Community Care Worker (CCW) affiliated with a Community-Based Organization reaches out to Barry that they learn about his two daughters, about the constant stress of providing consistent healthy meals to them. The CCW also learns about a larger, looming source of stress: the fear that he will not be able to keep them in their current home, for financial reasons. 

After talking to Barry, the CCW is better informed to prioritize different types of support, make recommendations, and make sure Barry actually gets the help he needs.

The CCW lives in the area and connects people to services in Barry’s neighborhood on a regular basis. They know which local food pantry is convenient for him to stop by on his way back from work, and will have food he and his daughters can eat. This is more than a band-aid, it is an ongoing resource for this family while budgets remain thin. 

Second, the CCW provides a coupon that drastically cuts the monthly cost of his meds, freeing up important finances for nutritious meals for his children. They also help him apply for utility assistance. With two jobs, Barry is strapped for time, and having the CCW help him fill out all relevant applications is critical to making sure it gets done. 

These interventions make a difference. They break the cycle. Barry can afford his medication every month and reduce his utility bill by 20 percent. He and his daughters are able to afford nutritious meals and stay in their home. 

Instead of a one-time email from a platform, or a one-time phone call, the CCW is able to build trust with Barry and disentangle the interrelated health and social challenges he and his family face. They are able to deploy a “right-touch model” for engaging Barry, communicating with him face-to-face because that’s his preference and following his preferences builds trust. They’re also able to focus on services that provide long-term solutions—like the ongoing reduced utility bill—instead of spot solutions that do a good job of checking a box, but don’t necessarily make a meaningful difference to Barry and his kids. 

This is a model that works! We've been deploying it in communities across the country at GroundGame.Health, leveraging a network of CBO partners who are best positioned to provide this local, person-to-person engagement. We use technology to do it at scale, by identifying cohorts for outreach, powering the flow of data from health plans to CBOs, and documenting not only which care gaps are identified, but also which care gaps are closed in our platform. Interoperable technology is, in fact, critical to making sure that health plans, hospital systems and CBOs—whose systems are not configured to work with one another—can collaborate to close these gaps. By showing proof of their good work and documenting which gaps are closed with our platform Implify™, CBOs are able to secure steady funding from health plans who want to invest their resources where they can make the biggest impact. 

But the gaps are only closed—and the impact only realized—because of people providing these last-mile solutions on the ground. We see it every day with members like Barry and so many others: by building a healthcare system where trust is at the center of how we reach people, engage them, and deliver the support they need, we can fundamentally change how people understand and access care. 

*Barry is based on a real person that GroundGame.Health worked with. His name and certain details about his case have been changed.

About GroundGame.Health

GroundGame.Health manages the complex connections between health plans, providers, and Community-Based Organizations to fulfill unmet social and care needs for people everywhere. Our closed-loop platform and trusted, local relationships allow health plans to connect their most challenging-to-reach members with the care and help they need—and drive better health and more equity as a result. Contact our team today to learn more.