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Managed care organizations (MCOs) are using social care navigators (SCNs) to address social needs. An intelligent support system framework using machine learning can help prioritize SCN efforts to reduce health disparities.

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Area of Science:

  • Health Services Research
  • Social Determinants of Health
  • Health Disparities Research

Background:

  • Managed care organizations (MCOs) increasingly recognize social drivers of health's impact on outcomes and healthcare utilization.
  • MCOs employ social care navigators (SCNs) and screen for social needs (food, housing, transportation).
  • Barriers exist for individuals with social needs in screening completion and receiving care, leading to high SCN caseloads and potential underidentification of highest-need individuals.

Purpose of the Study:

  • To develop a framework for an intelligent social engagement support system.
  • To address challenges in prioritizing social care navigator efforts for individuals with the highest social needs.
  • To reduce health disparities in socially-driven health outcomes within MCO contexts.

Main Methods:

  • Developed a framework for an intelligent social engagement support system.
  • Built upon the Health Care System domain of the National Institutes on Minority Health and Health Disparities' Health Disparities Research Framework.
  • Integrated learning health system, community-engaged approaches, and machine learning.

Main Results:

  • The framework aims to create an adaptable, multi-level system.
  • The system is intended to have numerous positive outcomes, including reducing health disparities.
  • The framework's application and adaptation in different MCO contexts are discussed.

Conclusions:

  • An intelligent social engagement support system framework can enhance the effectiveness of social care navigation.
  • Prioritizing SCN efforts through such a system can improve outcomes for individuals with the greatest social needs.
  • This approach holds promise for reducing health disparities driven by social determinants of health.