Proven Strategies and ROI for Solving Members’ Social Care Needs
Better understand how to effectively engage members, deliver hyperlocal, culturally tailored interventions, and ultimately improve outcomes while demonstrating a strong return on investment (ROI).
Nearly half of adults in the U.S. experience at least one unmet social need, and the journey to overcoming those challenges looks different for every individual. Whether it’s food insecurity, housing instability, transportation barriers, financial strain, or loneliness, these non-clinical factors have a powerful influence on a person’s ability to access healthcare and maintain good health. This was the central focus of our recent webinar with AHIP titled, Proven Strategies and ROI for Solving Members’ Social Care Needs.
Drawing on years of experience engaging members across all lines of business, Abner Mason, chief strategy and transformation officer, and Meredith Welsh, senior vice president of operations and head of service delivery at GroundGame.Health,shared actionable strategies, case studies, and proven results from tackling social barriers to care. The event was designed to help health plans and healthcare leaders better understand how to effectively engage members, deliver hyperlocal, culturally tailored interventions, and ultimately improve outcomes while demonstrating a strong return on investment (ROI).
The Problem: Social barriers impact clinical outcomes and costs
For decades, healthcare delivery in the U.S. has operated in silos, separating clinical care from social care. Yet as Abner explained, clinical outcomes are largely determined by what happens outside the exam room. Social needs frequently disrupt care plans, lead to higher healthcare costs, and prevent members from achieving their health goals.
Data from GroundGame.Health, collected from engaging hundreds of thousands of members, reveals that over 60% of members have at least one unmet social need, with the average person experiencing 3.4 social challenges. Importantly, this pattern holds true across all member types — not just Medicaid populations, but also Medicare Advantage, Commercial, Dual, and Marketplace members. This reality makes it clear that health plans must proactively address these social barriers to care if they hope to improve member outcomes, reduce avoidable utilization, and strengthen financial performance.
The Challenges: Why solving social needs is so difficult for health plans
Meredith outlined three challenges that health plans face in addressing members’ social needs at scale:
- Finding Appropriate, Hyperlocal Resources: It’s not enough to hand members a resource directory or a generic referral link. True support means confirming whether a local food pantry, housing program, or utility assistance provider has current capacity and meets the specific needs of the member (e.g. kosher food options,culturally sensitive services). That requires real-time, on-the-ground awareness.
- Ensuring Closed-Loop Referrals: Referrals alone don’t resolve social needs. Health plans must track whether members accessed services, received what they needed, and ultimately closed the gap. Without this, unmet needs persist, and valuable opportunities for care improvement and cost avoidance are missed.
- Supporting Members Who Can’t Self-Serve: While some members can navigate digital tools and community portals independently, many — particularly those with multiple, overlapping social needs — require a human touch. Members like Lisa, whose story was shared during the webinar, can’t resolve complex issues alone. Personalized, face-to-face, culturally tailored outreach is critical.
Scalable Solutions: Combine technologyand on-the-ground services
A recurring theme of the webinar was the indispensable role of community-based organizations (CBOs) in addressing social determinants of health. While health plans have the resources, they often lack hyperlocal relationships, cultural insight, and operational capacity to solve social needs directly. Unfortunately, most CBOs are too small to contract directly with large health plans due to compliance, insurance, and infrastructure hurdles.
GroundGame.Health acts as a bridge — contracting with health plans on one side and CBOs on the other, using its technology platform, Implify™ to coordinate referrals, track outcomes, and deliver real-time updates back to plans. This model allows health plans to quickly expand their social care reach without navigating hundreds of individual local contracts.
Meredith also introduced the “Right Touch” model, which stratifies members based on the level of support they need whether its digital resources for self-sufficient members, telephonic outreach for those needing moderate guidance, or in-person visits for high-need members requiring direct advocacy. This approach combines technology with human care coordinators and a national CBO network. In 2024, GroundGame.Health engaged over 600,000 members nationwide using this model, closing thousands of social care gaps while tracking measurable outcomes.
ROI: The financial case for social care investment
Beyond being the right thing to do, addressing social determinants of health delivers measurable ROI. Abner and Meredith both shared independent data from GroundGame.Health plan partners demonstrating:
- A $5 return for every $1 invested in social care services
- A 27% reduction in inpatient admissions
- An 18% reduction in avoidable emergency department visits
- A 25% increase in annual wellness visits
By removing social barriers, members are more likely to seek preventive care, avoid unnecessary hospital use, and adhere to care plans — saving money and improving outcomes. Through technology, local partnerships, and personalized outreach, health plans can improve lives, reduce costs, and strengthen communities. And with scalable infrastructure now available, there’s never been a better time to close the gap between clinical and social care.
