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Upstream

Social drivers & community

Housing, food, transportation, and benefits data joined with health outcomes to target programs.

Closed-loop referrals
48.2k
Housing-unstable adults
6.4%
Food-insecure households
11.2%
Transportation barrier
9.8%

Connected CBOs & networks

  • Unite Us (statewide)
    412 partners · closed-loop referral
    live
  • Feeding GA food banks
    Live inventory + delivery routes
    live
  • Atlanta Housing Authority
    Eligibility check API
    integrated
  • MARTA Reach (transport)
    On-demand medical rides
    live
  • Legal Aid · benefits navigation
    Warm handoff from clinics
    integrated

Outcomes attributed to SDOH closures

  • Diabetes A1c · -0.6 in housed cohort
  • ED revisits · -22% with rides program
  • WIC enrollees · 18 pts ↑ infant birthweight
  • SNAP-enrolled · 31% ↓ food-insecure score

Screening coverage

  • Medicaid plans · 84% screened annuallytracked
  • FQHCs · 92% screened at intaketracked
  • Hospitals (CMS HRSN) · 71%tracked
  • Schools · 38% (growing)tracked