How Eviset’s Social Care Data Platform is Supporting San Diego County to Improve Community Health Outcomes
San Diego County has long been regarded as a national leader in supporting community health and well-being. Home to Live Well San Diego – over 500 organizations formally collaborating to assure residents’ health and well-being, San Diego Connect – a premier Health Information Exchange (HIE), and a thriving Community Information Exchange (CIE) directory of social care services housed at 2-1-1, the County has consistently demonstrated its ability to deliver measurable improvements in health outcomes and cost savings by leveraging technology, data and the power of a high-performing community network.
Given that context, it has been a tremendous privilege and downright exciting for Eviset to serve the County to contribute to its next innovation in improving health outcomes and addressing health equity. In many ways, San Diego is leading the nation in optimizing engagement of social care providers – entities that provide services to address Social Determinants of Health (SDoH) like food insecurity, housing instability, and services for older adults (to name just a few), that evidence has shown to drive 80% of our health outcomes and offer potential to decreased healthcare spending.
Driving Healthcare Value:
Data-driven Analysis of Social Care
Since the beginning of 2024, Eviset has been conducting a comprehensive, countywide landscape analysis to evaluate the quality and capacity of social care providers that form the basis of California’s transformative “CalAIM” program supported by the State’s 1115 Medicaid waiver. In CalAIM parlance, social care providers that are part of the initiative are called Enhanced Care Management (ECM) and Community Supports (CS) services.
We are using our data platform to help the County better understand and map the landscape of ECM and CS providers in the County and how its Medi-Cal members are served. The deep intelligence we generate is already informing key questions about social care network adequacy, such as:
Understanding where members and providers are located/service coverage area
Identifying potential areas of geographic disparities or service gaps (e.g., no providers of specified services for specific Populations of Focus within certain zip codes)
Addressing issues of competition (a topic about which we have previously written)
Understanding more nuances about services, such as specialized focus or qualifications (e.g., serving Alzheimer's patients is different from serving justice-involved youth, even if the underlying service – nutrition, transportation, case management, etc. – is listed in the same service category)
Predicting future needs so social care providers can better develop staging plans to manage caseloads.
This is no small undertaking. San Diego is the second most populous county in California and the fifth largest county in the U.S. Of its 3.3 million diverse residents, more than one million are Medi-Cal (Medicaid) members. With nearly one-third of its population on Medi-Cal, the potential to make a significant impact is substantial, with the health and well-being of many lives being impacted.
Ensuring Member Experience is Central
To ensure Voice of the Member is deeply integrated in the work, we will also deploy our scalable member experience data solutions. At Eviset, we have always viewed member experience feedback as the key that moves a community from being underserved to being… , well, served. Gathering high-quality member experience data, therefore, is foundational to efforts aimed at moving the needle on health initiatives that address SDoH and health equity.
We will leverage our deep experience supporting social care providers with member experience surveys, objective validated measures, efficient and low burden data capture and analytics. For this work in San Diego, we will elicit direct community member feedback on how social care services are or are not meeting their needs.
Collaborative Approach with Stakeholders
Given San Diego County’s strong commitment to community collaboration, our approach also involves engaging with sector stakeholders, including ECM and CS providers and Managed Care Plans, who are part of the co-design process.
In achieving these important goals, Partners in Care Foundation has been an invaluable co-partner, validating the utility of the data insights from the perspective of what is of highest value for the day-to-day operations of ECM and CS providers and the clients they serve. The work in San Diego County has benefited from their 30 years of hands-on experience as a social care provider and, now, Community Care Hub in Southern California serving numerous health plans, health care providers, and government entities.
The solutions Eviset is deploying in San Diego are also deeply informed by our extensive engagement with community-based organizations (CBOs) and other social care providers we have served as clients. As a trusted Dept of California Healthcare Services (DHCS) technical assistance provider for CalAIM, we have collaborated with numerous Enhanced Care Management (ECM) and Community Supports (CS) providers, supporting them with data-driven strategies to navigate the transition to contracting with Managed Care Plans and delivering services under 1115 waivers such as CalAIM. Through these collaborations, we have witnessed firsthand how our data platform has helped social care providers sustain and grow services and contract more effectively with managed care plans.
The Power of Social Care Interventions
This is an unprecedented time of growth and investment in social care interventions, which have the power to address basic health needs before they escalate into high-cost medical crises. As we continue to deepen our work – in San Diego, in California, and in the Nation – we are deeply impressed and humbled on a daily basis to support our country’s passionate, innovative and committed social care sector.
This blog was written by Julie Lawrence, CEO of Eviset who expresses her deep appreciation of the extended County-Partners in Care-Eviset team that is supporting this work. The views expressed are her own.
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