Advancing Health Equity for Vulnerable Populations


Many environmental, socioeconomic and systemic barriers to care prevent diverse and disenfranchised communities from living their healthiest lives. COVID-19 only highlighted this issue further.

The highest rates of COVID-19 infections and deaths were among Black, Hispanic, American Indian or Alaska Native (AIAN), and Native Hawaiian or Other Pacific Islander (NHOPI) people. At the start of the pandemic, researchers were concerned that the LGBTQIA+ community would face health and economic risks due to the virus. These concerns were later validated as studies identified the higher rates of underlying conditions for the community, which contributed to widespread hospitalizations and deaths from COVID-19.

Inequities in healthcare played a major role in infection and death rates during the pandemic, and these barriers to care need to first be resolved to improve health outcomes.

States Initiate Health Equity Programs

Just as the Centers for Medicare and Medicaid Services (CMS) positions health equity as a top priority for Medicare plans at a federal level, states are implementing new strategies to reduce health disparities.

Each state is taking a different approach to advancing health equity, from community-specific programs to statewide initiatives to improve access to care for all members. For example, New York State’s Taskforce on Maternal Mortality and Disparate Racial Outcomes implemented a “multi-pronged initiative” to reduce maternal mortality rates with a focus on racial disparities.

On the opposite coast, California Advancing and Innovating Medi-Cal (CalAIM) is a five-year program designed to address three goals within the state:

  • Identify and manage comprehensive needs through whole-person care approaches and social drivers of health.
  • Improve quality outcomes, reduce health disparities and transform the delivery system through value-based initiatives, modernization and payment reform.
  • Make Medi-Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility.

As more states initiate health equity programs and regulations to address social determinants of health (SDOH), health plans are challenged to refine their engagement strategies to meet the needs of vulnerable and disenfranchised communities. Not only does this require plans to take a long hard look at healthcare disparities based on race and ethnicity, but they also must implement strategies to close care gaps for members who:

  • Are experiencing homelessness or housing instability
  • Are in the foster care system
  • Are at risk of being institutionalized
  • Have been released from prison
  • Have disabilities
  • Have serious mental illness and substance use disorders 

Medicaid and Dual Eligible Special Needs Plans (D-SNP) can improve health outcomes for vulnerable populations by addressing health-related social needs at the community level, but plans need the right tools to optimize their initiatives. To better understand, target and improve health outcomes for vulnerable populations, here are three immediate steps health plans can take.

SDOH-Focused Data Aggregation

Expanding access to care for diverse and hard-to-reach members begins by understanding the barriers that prevent members from living their healthiest lives. These barriers will vary by community, requiring plans to get more granular in how they capture member data.

For example, recent research has focused on how zip codes impact health outcomes, including the impact of segregation and infrastructure on life expectancy. This can be seen in urban areas with limited access to healthy food and pharmacies or rural communities where a lack of reliable transportation results in higher care gaps for low-income or disabled members.

Being able to drill down into SDOH at a community level allows you to better understand why certain populations experience disparities and how to improve them. Healthmine helps health plans surface SDOH insights through:

  • Comprehensive member records: Integrating clinical and non-clinical data into a centralized dashboard empowers plans to create a whole-person view of a member. Filtering member records based on locations, demographics, compliance rates and survey responses can shine a light on common SDOH to build targeted outreach lists.
  • Digital-first, member-friendly surveys: Members can provide more details about what barriers to care they are facing when you ask the right questions. Our digital, NCQA-certified Health Risk Assessment (HRA) allows you to directly field questions about SDOH from members  to identify housing, transportation and food insecurities alongside other important risk factors like alcohol dependency and exercise habits. Plans that partner with Healthmine have access to First Time Experience surveys, which are surfaced to members upon program registration, and provide further insights into SDOH.

Personalized, Data-Driven Campaigns

There is no one-size-fits-all approach for engaging diverse and vulnerable communities in their healthcare. Members who are more digitally inclined may prefer emails, text messages and smartphone apps for communicating with their health plan. Members experiencing housing insecurities or homelessness may still have access to internet services, making digital engagement vital for connecting them with community resources. In contrast, members with lower incomes or in rural areas may rely on mailers and phone calls to learn about healthcare resources.

Instead of using generic member outreach to cast the widest net on your populations, focus on building coordinated, omnichannel campaigns that zero in on specific communities and their needs. In Healthmine’s experience, plans see stronger success with smaller campaigns that provide more personalization for members, resulting in higher conversion rates and better control over budgets.


While partnering with Healthmine to implement an outbound call campaign, a health plan improved gap closure by 32% for time-sensitive appointments by directly calling and assisting members in getting the care they needed.


Throughout all your engagement strategies, keep in mind the role language plays in improving access to care. Relying on English-only materials risks alienating members with limited English proficiency, resulting in low compliance rates. However, using culturally relevant, multilingual messaging builds trust, educates members and engages them with their health. To ensure every member has access to health resources, Healthmine enables plans to communicate with members in up to 140 languages, including Spanish, Chinese, Mandarin and Tagalog.

Tailor Rewards to Member Needs

As you identify SDOH impacting your member populations and optimize your campaigns to improve engagement, do not forget about how you motivate members. Rewards have a strong impact on closing care gaps and improving healthy behaviors, especially for low-income members, but they must be relevant to their needs.

Allowing members to choose from a robust selection of gift cards from popular and regionally relevant stores, restaurants and brands gives them control over how they redeem their rewards. Plans that leverage Healthmine’s rewards and incentives solutions can customize which healthy activities they reward and what types of rewards they will offer based on retailers near their members.

However, plans can also tailor the rewards to address specific SDOH. For example, incorporating food boxes into rewards programs allows members in food deserts to access fresh produce. Plans can pair these rewards with preventive activities like completing a wellness visit with a primary care physician or submitting HRAs to better identify risks in vulnerable populations. Members who are pregnant or have recently had children may also be motivated to complete well-child visits by merchandise rewards like diapers, children’s toys or school backpacks.

To address the complex needs of vulnerable and diverse populations, plans should design flexible rewards programs that empower members to make healthy choices while acknowledging the challenges they face due to SDOH.

Optimizing Health Equity Initiatives with Digital Tools

Advancing health equity for vulnerable populations requires the technological capabilities to ingest multiple data sources to identify SDOH and inform targeted engagement campaigns that connect diverse and underserved communities to care. Coordinating outreach at scale for complex populations is difficult when balancing internal resources and operational capacity.

Incorporating the right digital tools into your health equity initiatives simplifies the process of designing and launching data-driven quality improvement strategies. To help Medicaid and D-SNP plans move from data to insights to action, Healthmine’s suite of digital solutions centralizes data aggregation, outreach and rewards programs into a single platform. Following a 90-day implementation period, plans can initiate scalable, member-centric campaigns to address SDOH and expand access to equitable healthcare.

Access Healthmine’s member engagement solutions to refine your health equity programs and bridge gaps in care for complex and diverse communities.

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