Spatially Health

What if your care team could manage more patients without working longer hours? That question captures one of the biggest opportunities in healthcare today. Every day, care teams are doing incredible work to support patients with complex medical and social needs. They're helping people find food, transportation, housing, and stability, while still meeting clinical goals and regulatory demands. But even the most dedicated teams can only do so much when their time and tools are stretched thin. The challenge isn't about effort. It's about focus. When every patient has needs, and every moment counts, knowing where to start can make all the difference. Teams that can quickly see who is most at risk and understand what type of support will make the greatest impact are able to act earlier and more effectively. Across the industry, leading organizations are shifting from reactive care to proactive coordination. They are using data-driven insights to bring clarity to complex caseloads, helping care teams prioritize their time and strengthen patient relationships. This ensures not just fewer missed opportunities or reduced utilization, but better experiences for both patients and the people who care for them. At Spatially Health, we believe that when care teams have clear direction and the right insights, they can achieve more than ever before. Our approach focuses on matching patients to the right social services, addressing barriers early, and making every touchpoint meaningful. When care management becomes simpler and more strategic, capacity grows naturally. And when capacity grows, so does the ability to make lasting change in the lives of patients and the communities they live in. #ThinkSpatially #CareManagement #SocialDeterminantsOfHealth #ValueBasedCare #ACOs #Technology #DigitalHealth #HealthcareInnovation

If 80% of health outcomes happen outside the clinic, why do most strategies still start inside it? When we talk about improving health outcomes, it's easy to focus on medical care. But the truth is, most of what drives health happens beyond the exam room, such as where people live, what they eat, how they get around, and the stability of their environment. These social and environmental factors often determine whether a person can get to their appointments, manage their medications, or recover safely at home. Without addressing them, even the most advanced medical interventions can fall short. That's why social care has become an essential part of value-based care. When social and clinical support align, patients thrive and systems perform better. But achieving that alignment requires more than goodwill. It requires structure, focus, and strategy. A sustainable social care strategy means identifying who needs support most, coordinating resources efficiently, and continuously learning from outcomes. Without a clear framework, efforts can become fragmented, inconsistent, and difficult to scale. To build a social care strategy that's both effective and sustainable, healthcare leaders can focus on four key priorities: - Target the right patients. Use data to find high-risk individuals and intervene early with the right support. - Know what's reimbursable. Leverage Medicaid, CMS, and community partners to fund essential services. - Support care teams. Equip teams with tools and data so they can focus on patients, not paperwork. - Measure what works. Track outcomes and use insights to refine programs and improve results. By turning data into direction, healthcare leaders can make social care practical, measurable, and lasting for both patients and the system as a whole. Better care starts with understanding what people need to live well. #ThinkSpatially #ValueBasedCare #PopulationHealth #CareCoordination #SocialDeterminantsOfHealth #ACOs #Innovation #DigitalHealth

Sometimes the best care happens with a wrench, not a stethoscope. Programs like the Community Aging in Place-Advancing Better Living for Elders (CAPABLE) model remind us that improving health outcomes does not always require a clinical breakthrough. Often, it begins with the simpler task of creating safe, supportive environments where people can live independently and with dignity. In CAPABLE, dual-eligible Medicaid and Medicare beneficiaries who face challenges with daily activities are paired with an Occupational Therapist, a Registered Nurse, and up to $1,300 in home repairs or assistive devices. The total cost averages $2,825 per participant. Yet studies have shown that these small, targeted interventions lead to average savings of more than $10,000 per member each year through reduced hospitalizations. Those savings are important, but the true impact is deeper. When people are able to stay safely in their homes, they maintain confidence, stability, and connection to their communities. That sense of independence translates into measurable improvements in health and quality of life. For leaders focused on value-based care, this model offers a powerful example of what it means to treat the whole person. It highlights the value of collaboration across disciplines and the potential to achieve stronger outcomes by addressing real-world barriers to health. The challenge now is scale. How do we identify which individuals would benefit most from home-based supports? How do we make it easier to coordinate between clinical teams and community partners? These are the questions that will define the next chapter of care delivery. As care continues to move beyond the walls of the clinic, programs like CAPABLE point to what's possible when we look beyond traditional boundaries. Sometimes progress begins not with a new medication or device, but with a safer home, a repaired step, or a simple modification that makes daily life easier. What steps is your organization taking to move care into the home? What challenges are you working to solve as you do? #ThinkSpatially #ValueBasedCare #ACO #PopulationHealth #WholePersonCare #HealthcareInnovation #Medicare #DigitalHealth #Technology

Most ACOs already have the data. The real challenge is knowing how to turn it into action that improves outcomes and drives measurable results. In value-based care, success is not defined by the volume of outreach, but by how focused and effective that outreach can be. For ACOs managing thousands of patients, patient prioritization provides the clarity needed to act with purpose. Every patient has needs, and every care team has limits. Prioritization helps identify who to reach first and how to direct resources toward the highest-impact opportunities. It bridges the gap between data and decision-making, turning information into action. Traditional outreach models rely heavily on clinical data like utilization rates and chronic conditions. While useful, these models often overlook the social factors that shape health outcomes, like housing, food access, and transportation. Without this context, outreach becomes reactive instead of proactive. Integrating social risk data with clinical priorities gives ACOs a more complete view of their populations. This insight uncovers hidden barriers to care and highlights the patients who are both most in need of support and most likely to benefit from timely outreach. When prioritization aligns with organizational goals, outreach becomes not just efficient but meaningful. Care teams can focus on the right patients, close more care gaps, and achieve measurable improvements in quality and cost. As value-based care continues to evolve, the ACOs leading the way are not the ones doing more outreach. They are the ones applying focus, precision, and data-driven clarity to every decision they make. #ThinkSpatially #ValueBasedCare #ACOs #PopulationHealth #CareManagement #SocialDeterminants #SDOH #DigitalHealth #Innovation #Technology

The smartest cost-saving strategy for employers might not be what it seems. The path to spending less on care begins by investing more in health. Miami-Dade County, a self-insured employer with 31,000 employees, began exploring a switch from Florida-based AvMed to national insurer Aetna after the mayor issued a proposal to do so. The move would save $40 million, which is about 6.6% of annual costs. On the surface, that looks like progress and a rare win in the complex math of healthcare spending. But it also raises a deeper question about whether we are chasing short-term savings or building long-term value. For risk-bearing organizations like Miami-Dade, the real opportunity goes beyond plan design. It lies in prevention, early intervention, and building stronger local ecosystems of support. When employees have access to reliable transportation, affordable housing, healthy food, and safe environments, they use fewer high-cost healthcare services and stay healthier overall. These are the factors that drive outcomes, engagement, and cost trends year after year. Yet too often, they sit outside of the benefits conversation. What would happen if the same level of attention and strategy that goes into selecting a new insurer went into connecting employees with community-based resources that address their everyday barriers to health? When healthcare and government align around these priorities, the impact is tangible. Employees stay engaged. Costs stabilize. Communities thrive. And the dollars that once left the county in administrative fees can instead be reinvested locally, where they do the most good. That is what it means to invest in health instead of just care. The ROI isn't only measured in renewal rates. It's reflected in healthier people, stronger organizations, and more resilient communities. Healthcare and health are local. And the organizations that understand that will lead the way toward a more sustainable future for everyone. #ThinkSpatially #HealthCare #SDOH #Miami #Florida #MDC #Technology #EmployeeBenefits #ValueBasedCare #Innovation

For years, risk stratification has helped value-based care organizations identify high-risk members and allocate resources more efficiently. Yet many models still rely almost entirely on claims and clinical data. These inputs are essential, but they overlook the social and environmental realities that shape a person's life, which is what often drives health outcomes in the first place. Social Determinants of Health (SDOH) bring that missing context into focus. They help explain why members struggle to stay healthy, follow care plans, or access services that keep them well. Understanding those barriers is essential for any organization aiming to deliver care that is both equitable and effective. Integrating SDOH into risk stratification doesn't just enhance prediction. It changes how teams prioritize, engage, and act. By layering social insights on top of clinical data, organizations can move from reactive to proactive care strategies that truly meet members where they are. Here's what this approach makes possible: - Smarter member targeting: Identify individuals at risk due to social and environmental barriers that traditional models often miss. - Proactive, preventive care: Use predictive insights to intervene earlier and reduce avoidable emergency visits or hospitalizations. - More meaningful engagement: Personalize outreach to each member's context, improving participation and care plan completion. - Operational efficiency: Focus care coordination time on the right members at the right moment, increasing productivity without adding staff. - Improved performance: Strengthen quality measures, reduce unnecessary costs, and align teams around actionable, real-world insights. As value-based care evolves, successful organizations will be those that view risk through both a clinical and social lens. Incorporating social risk data into analytic models gives care teams a clearer understanding of member needs and a stronger ability to act before issues escalate. The goal is not more data but better direction. #ThinkSpatially #ValueBasedCare #SDOH #PopulationHealth #ManagedCare #CareCoordination #DigitalHealth #Technology #Innovation

What if patient care and organizational goals were not competing priorities, but parts of the same strategy? Balancing the two does not have to be a constant struggle. Care teams are focused on meeting patient needs, while leadership is focused on measurable outcomes. When these priorities are aligned, both can move forward together. And it all begins with one of today's buzz words: Clarity. Care teams need to know which patients to prioritize and why. Leadership needs visibility into how those efforts are driving measurable impact. Alignment creates momentum, and momentum drives progress. Measuring outcomes must also be seamless. While social needs are often harder to capture than clinical data, they are equally important. Understanding the daily challenges patients face allows for better resource allocation, minimizing avoidable emergency visits, enhancing risk scores, and increasing completion of Annual Wellness Visits. Social workers cannot do this work alone. Finding and coordinating community services should be straightforward, supported by systems that make the process efficient, so more time can be spent addressing needs rather than managing lists. Leaders also need to see what is at stake. Every social barrier left unaddressed leads to higher costs through readmissions, emergency visits, or missed preventive care. Addressing these barriers is not only the right thing to do, it is also the practical way to optimize reimbursement, strengthen risk adjustment, and maximize shared savings. At its core, better care coordination benefits everyone. Patients receive the support they need, care teams are empowered to focus on impact, and organizations are able to achieve sustainable success. #ThinkSpatially #ValueBasedCare #AccountableCare #CareCoordination #HealthcareInnovation #ACOs #DigitalHealth #Technology

Attribution is not something you win once. It is something you earn every day by keeping patients engaged. Protecting and growing it requires more than clinical care alone. It means understanding the realities that shape patient engagement every day. When patients disengage, it is rarely because they do not care about their health. More often, barriers like food insecurity, transportation challenges, or caregiver strain make it difficult to follow through. These factors directly affect whether patients complete screenings, keep appointments, or stay connected to care teams. Clinical and claims data reveal what has already happened. Social risk data adds the forward-looking context that helps identify which patients may face challenges and why. Together, these insights create the chance to act earlier, strengthen relationships, and support patients in ways that are both practical and meaningful. Consider Annual Wellness Visits. A broad outreach campaign may not succeed if patients cannot arrange transportation or do not have consistent access to food. By layering social risk insights into care strategies, outreach can be prioritized, referrals coordinated, and services aligned so patients can complete visits successfully. This shifts the conversation from simply asking patients to show up, to helping them figure out how. Attribution is about engagement. And engagement grows stronger when patients feel supported in both their medical care and their daily lives. By embracing social risk insights, ACOs can build healthier communities, strengthen trust, and create long-term stability in value-based care. #ThinkSpatially #DigitalHealth #ValueBasedCare #ACOs #HealthcareInnovation #Technology #Innovation #CareCoordination

Nearly 27% of Americans are behind on screenings and immunizations. For ACOs and MCOs, this is not just a statistic. It is an opportunity to rethink prevention. Value-based success requires more than providing clinical care. It means creating the conditions where patients can stay healthy, engaged, and supported over time. Preventive care is essential to this work, yet many patients face barriers that limit access and follow-through. Early detection of chronic conditions, such as diabetes, can significantly alter the course of both individual patient health and overall organizational performance. However, prevention extends beyond the examination room. Factors like income, housing stability, and access to healthy food often influence whether patients can follow medical advice and adhere to their care plans. This is where the next generation of value-based care is emerging. At Spatially Health, we collaborate with ACOs and MCOs to integrate insights on social risks directly into care delivery. By pinpointing which patients to prioritize and connecting them to the care they need, we facilitate prevention that is actionable and sustainable. The future of value-based care will be led by organizations that view prevention as both a clinical and social strategy. Those that do will see healthier populations, fewer avoidable hospital visits, and stronger quality and financial outcomes. #ThinkSpatially #ValueBasedCare #PopulationHealth #AccountableCare #PreventiveCare #ACOs #Innovation #Technology

The future of better outcomes lies in how we operationalize SDOH, not just how we measure it. Collecting data on food insecurity, housing, or transportation barriers is an important step, but it is not enough on its own. When social risk data remains siloed or disconnected from care, patients continue to face challenges that could have been addressed, and care teams are left without the full context they need to succeed. When this information is operationalized, it becomes more than data. It becomes a driver of stronger care delivery, smarter resource allocation, and deeper community connections. By integrating SDOH insights into workflows, organizations are able to see patients more holistically, respond more effectively, and achieve measurable outcomes. Operationalizing SDOH requires more than just screening. It means enriching risk stratification with social context, equipping care teams with actionable recommendations, coordinating referrals to trusted community providers, and tracking outcomes to understand what truly makes a difference. Organizations that treat SDOH as part of their core infrastructure are setting a higher standard for value-based care that is both patient-centered and sustainable. The most effective strategies share common traits. They establish clear goals with measurable outcomes, design scalable workflows that integrate into daily care, build strong social care networks, and create referral systems that ensure accountability and follow-through. Predictive analytics enhances this foundation by helping teams anticipate risks, intervene earlier, and focus resources where they are needed most. As healthcare costs rise and patient needs become more complex, addressing social risk is not a secondary task. It is a vital step in delivering high-quality care and ensuring the long-term sustainability of health systems. Organizations that take action now will be better positioned to improve outcomes, strengthen trust, and create care models that truly meet patients where they are. #ThinkSpatially #DigitalHealth #Technology #ValueBasedCare #HealthcareInnovation #SDOH #HealthcareLeaders #Innovation