A Nebraska community proactively addresses social drivers of health

Community health navigators, a technology platform, and a strong network of community-based organizations helped Medicaid clients in Omaha, Nebraska connect with resources and address their nonmedical health needs. Activate Care, a for-profit company and leader in social risk management solutions, partnered with a direct health care company and a Nebraska managed care organization to fund a pilot program focused on affecting social determinants of health in a Medicaid population in the Omaha area. They began with a community assessment that identified the resources available, barriers to obtaining care, root causes of disparities, and assets within the community. Leveraging the Activate Care application to streamline care and resource navigation processes, they launched the evidence-informed intervention, which consisted of patient outreach, enrollment, social need identification, community resource referral, and engagement with community-based organizations. Activate Care’s Community Health Navigator (CHN) team proactively partnered with clients, providing behavioral coaching on goals and improving overall engagement and health confidence. They encountered hurdles related to CHN technology literacy, telephonic screening and engagement limitations, and resource access barriers but successfully identified, screened, and engaged residents in an intervention to prioritize and achieve goals.