The Civic Engine is working with New Mexico Health Connections, a statewide cooperative, non-profit health plan in New Mexico to apply the Roots to Health Screening Tool and Survey to improve population health. The project, titled Roots to Health New Mexico, will use the Roots to Health Survey to assess health resources among plan members with chronic diseases, allowing the plan to both focus the efforts of community health workers on social and economic barriers to care and quantify the impacts of unmet needs on health care quality, utilization, and costs at the population level. New Mexico Health Connections anticipates that the new population health intelligence will inform the health care plan’s strategies to mitigate social and economic care risks. Roots to Health New Mexico will also contribute lessons for the region and the country on data-driven approaches to measure, monitor, and act on social and economic risk factors.
Effective health care for economically and socially vulnerable populations requires the routine assessment of basic needs and assistance with the navigation to responsive community resources. The Civic Engine is working with the Roots Community Health Center in Oakland, California to integrate a pro-active assessment of basic health needs into their routine clinical practice. The Center aims to use community health workers to assist patients in managing their needs to use the associations between needs sufficiency and health outcomes at the population level to inform County efforts to align social service and healthcare service delivery.