From the Exam Room to the Community: Addressing All the Drivers of Health
Key Highlights:
- Addressing a person’s whole-health needs — such as access to nutritious food or transportation — provides them with support that can drive better health.
- Elevance Health’s Community Connected Care program puts this approach into action by connecting members to community resources through data insights, referrals, and direct outreach.
- Through its Social Drivers of Health Provider Incentive Program, Elevance Health supports care providers in assessing nonmedical needs, making community referrals, and following up to promote holistic, proactive care.
The familiar path to getting healthcare for many people starts with a symptom, moves to a doctor visit, and might continue with a prescription or referral to a specialist.
While these steps can bring someone closer to feeling better, what if they’re not getting enough to eat or don’t have a ride to medical appointments?
Acting on those additional nonmedical factors helps address the root causes that can drive better health, and may help people avoid more costly medical care. So what’s the way forward when the remedy isn’t found in a pharmacy, but in a bag of groceries or a bus pass?
Overall, as much as 80% of health stems from what happens outside the doctor’s office — such as the food people eat, the air they breathe, and whether they have a safe and stable place to live. Research points to the significance of addressing these types of whole-health factors:
Community Connected Care
If so much of what drives health happens outside the walls of medical facilities and inside our communities, solutions for better health should reside there, too.
The Community Connected Care program offers a comprehensive approach for assessing and addressing the whole-health needs of members of Elevance Health-affiliated plans. Needs are identified through multiple channels, including:
- Requests made by members through the Sydney Health app.
- Referrals from a care provider, like a doctor, or from an Elevance Health-affiliated case manager.
- Data-driven insights derived in part from our proprietary Whole Health Index (WHI). The WHI reflects a person’s relative health over time on a scale of 0 to 100, taking physical, behavioral and social factors into account and identifying areas where they may need additional support.
Once an assessment is complete and a member is referred for inclusion in the program, community care coordinators reach out via text, phone, or in person and work to connect them to the appropriate resources. That can mean helping members access benefits already available through their health plan or connecting them with a community-based organization (CBO), like a food bank that can provide nutritious food or a housing-focused nonprofit that can offer home repairs.
Since 2023, Community Connected Care has engaged approximately 300,000 members of Elevance Health-affiliated health plans and provided more than 450,000 resources,* including referrals and other services. For example, the program helped a member named Eduardo connect with the nonprofit Partners in Care Foundation to address whole-health factors that included a language barrier.
"When we look at drivers of health, it’s clear that medical care alone can’t move the needle,” said Dr. Shantanu Agrawal, chief health officer at Elevance Health. “Community Connected Care addresses the social factors that influence health head-on."
Social Drivers of Health Provider Incentive Program
Care providers can support a person’s health not just through medical care, but also by spotting needs beyond the exam room that might otherwise be overlooked.
Through the Social Drivers of Health Provider Incentive Program, care providers are encouraged to assess Elevance Health-affiliated Medicaid members for factors affecting their whole health and for adverse childhood experiences (ACEs), earning additional payments for doing so. ACEs are potentially traumatic events experienced during childhood — such as interpersonal violence — that can have long-term consequences on a person's health and well-being.
When we look at drivers of health, it’s clear that medical care alone can’t move the needle.”
Chief Health Officer, Elevance Health
Primary care physicians, doulas, behavioral health specialists, and other care providers also earn incentives by:
- Using the findhelp platform to refer members to CBOs that can provide support.
- Following up on referrals and documenting when a member received help.
- Sending diagnosis codes that match a member’s personal situation through the billing process to Elevance Health-affiliated Medicaid plans. This allows plan case managers or other associates to offer support as needed.
The care provider incentive program launched as a pilot in four Medicaid health plans in 2020. In 2025, approximately 600 care provider groups were enrolled in the program across more than 20 Medicaid plans. More than 200,000 member assessments and over 112,000 referrals have been made on behalf of members since 2020.*
"Incentive models like this one transform healthcare from a system that reacts to illness into one that actively supports whole health,” said Dr. Catherine Gaffigan, president of Health Solutions at Elevance Health. “By addressing social drivers, care providers help ensure members receive the support they need for their health and well-being."
*Sources: Internal Elevance Health data