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Social Risk Assessments and Closed-Loop Technology

Critical in addressing health equity, Inclusive CareBridge offers an all-encompassing Social Risk Assessment Tool designed to enable healthcare providers to assess and monitor the social needs of their patient population by offering immediate solutions and resources to bridge gaps in care, resulting in improved patient outcomes and health equity.​

  • (15) SDoH & Custom Assessments (including HEDIS SNS)

  • Multi-language and Audio to address language and literacy barriers

  • One source of SDoH data and Z-code collection

  • Immediate feedback and education regarding community based organizations and resources based on risk factors via text and email to each individual

  • Reporting tools for GAP closure and assistance with submitting for HEDIS and MIPS

  • Z-Code mapping

  • Aggregated SDoH data by population 

  • Sort by zip code(s), SDoH element, Community Based Organization Engagement and other meta data

  • Closed-loop solution

Volunteers Packing Food

Virtual Community Health, Coaching and
Resource Coordination

Coaching for Social Determinants of Health personalized assessment review and resource coordination is a valuable approach to addressing the unique needs of individuals or communities affected by SDoH. By addressing the underlying social and economic factors that influence health, it becomes possible to work towards health equity and better health outcomes for everyone.

  • Review of assessments which identify specific social, economic, and environmental factors

  • Resource Identification and education on the available resources and support systems that address an individual's SDoH disparities such as community organizations, government programs, and other services

  • Education and health literacy to help each individual make an informed decision regarding resources

  • Culturally sensitive and respectful of the values, beliefs, and preferences of the individuals or communities they reside

Checking Blood Pressure

Primary Care Resource Coordination

Checking Blood Pressure

Primary Care Resource Coordination

Assessing primary care utilization is crucial for improving healthcare delivery. Tailoring services to patient needs enhances accessibility and effectiveness. Efficient appointment coordination promotes preventive care, reducing emergency room overuse and improving outcomes. These efforts advance equity in healthcare, boosting access and treatment effectiveness for diverse communities.

  • Evaluation of current Primary Care Utilization

  • Coordination of Primary Care Appointment

  • Reduction of Emergency Room Overutilization

  • Improved overall healthcare access and treatment 

Taking a Break

Behavioral Mental Health Screening, Referral and Treatment

Behavioral mental health screening, referral, and treatment are essential in healthcare, extending care beyond physical health. Early detection through screening allows timely interventions, reducing escalation risks. Effective referral pathways ensure tailored care, including therapy and medication. Integrating mental health into primary care fosters resilience, enhancing overall health outcomes and quality of life.

  • Coordination of Mental Health Provider Evaluation

  • Virtual Behavioral/Mental Health Access

  • Mental Health Assessment

  • Virtual Therapy

  • Medication Prescribing and Management

Understanding the impact of SDoH is essential for healthcare providers, policymakers, and public health professionals because it helps inform interventions and policies aimed at reducing health disparities and improving overall population health.

By addressing the underlying social and economic factors that influence health, it becomes possible to work towards health equity and better health outcomes for everyone.

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