Beyond Medical Care
We know the truth: a patient's health is determined more by their zip code than their doctor's expertise. Social determinants of health—housing, food security, transportation, social isolation—drive 80% of health outcomes. Yet most healthcare systems haven't figured out how to systematically address them.
The SDOH Navigation Problem
Clinicians identify that a patient needs housing assistance or food support, but then what? Social workers are overwhelmed. Patients don't know where to go. Resources sit underutilized. The result: patients' conditions worsen, they return to the ED repeatedly, and outcomes suffer.
AI-Powered Navigation Solutions
Automated Screening
Digital forms screen patients for SDOH needs at every touchpoint. No extra burden on clinicians—the AI handles it. Screens identify which resources each patient qualifies for.
Intelligent Matching
The AI connects each patient with appropriate resources—local food banks, housing programs, transportation services, mental health support. Match quality improves outcomes.
Real-Time Referral Management
Automated referral to community partners. Real-time status tracking. Follow-up with patients ensures they actually access services. No referrals fall through the cracks.
Outcome Tracking
Closed-loop integration. We measure whether SDOH interventions actually improve clinical outcomes. Data informs program improvements.
Proven Clinical Impact
- ED Readmission: Reduced by 15-20%
- Hospital Length of Stay: Decreased 2-3 days
- Chronic Disease Control: Better HbA1c, BP control in supported patients
- Patient Satisfaction: HCAHPS scores improve 8-12 points
- Financial: Net savings of $3-7 per dollar invested
Compliance & Integration
We integrate with your EHR (Epic, Cerner, Athena) to identify high-risk patients and trigger SDOH interventions. CMS-compliant coding. Supports HEDIS measures and Star ratings.
Addressing Health Equity
Our algorithms are built to identify disparities and ensure equitable resource allocation. We help healthcare systems move beyond "diversity" into action.
Get Your Organization Started
Whether you're a community health center, ACO, or health system, we can deploy SDOH navigation powered by AI. Start with a pilot, then scale. Contact us for a free consultation.