The disproportionate impact of COVID-19 on the country’s most vulnerable populations has been well documented throughout the duration of the pandemic. The past year has exposed just how severely socioeconomic factors can exacerbate the symptoms and impact of illness.

John Hopkins University recently published research that highlights the importance of understanding how the Social Determinants of Health (SDOH) impact access to healthcare and health outcomes in underserved communities. It cited Socially Determined for our work with the State of Maryland COVID-19 task force on vulnerable populations to help identify high-risk populations for proactive outreach and support.

The State of Maryland COVID-19 task force on vulnerable populations brought together key leaders across public and private organizations to form a coalition that would create and implement a strategy to address the unique needs of populations at greatest risk for COVID-19 morbidity and mortality. The genesis of our relationship with the task force on vulnerable populations began when Dr. Susan Mani, chief population health officer for LifeBridge Health and head of the State of Maryland COVID-19 task force for vulnerable populations, diagnosed the need for a data-driven approach to determine which targeted resources were needed.

“As we brought groups together, we recognized the need fora data-driven approach to identify the most vulnerable amongst our populations,” said Dr. Mani. “One of the first things I did after that was say, ‘Who could we bring to the table to be part of our task force and help us with this extremely important mission?’ I knew Socially Determined from work we’ve done together  at LifeBridge around exactly these kinds of things – thinking about SDOH – and the team was the perfect fit for us to achieve that.”

We were fortunate to have a running start for this initiative, as our data science team had developed a specific risk metric around COVID-19 and susceptibility at the onset of the pandemic. The “COVID-19 Susceptibility Index,” which furthered our pioneering work quantifying social risk, examined disease burden, population density, economic stress, public infrastructure data, and commercial data related to businesses and communities to stratify risk at scale. We already mapped out community risk below the neighborhood level for the entire country, which enabled us to examine the state of Maryland’s Medicaid and Medicare population at a 200-square-meter level to rapidly pinpoint populations at the greatest risk and optimize outreach efforts.

We used our SocialScape® platform to stratify 2.6 million individuals and communities, and within days, we were able to map out different areas in the state of Maryland with the highest volume of at-risk populations to coordinate targeted, proactive outreach. We incorporated data from CRISP, the statewide health information exchange, to analyze each individual with information pertaining to age and gender, as well as WHO and CDC guidelines around the 32 diseases that increase the risk for COVID morbidity and mortality.

By capturing disease flags for each of the comorbidities and layering them into the analysis for risk stratification, SocialScape enabled us to pinpoint the people most in need among a population of 2.6 million. Based on our analysis, more than 1,000 of the highest-risk individuals were treated or tested directly in their homes or housing sites within 25 days of stratification. This work revealed a COVID-19 positivity rate more than double the state average. Additionally, this visibility enabled the state to connect members of these communities to resources many had not previously received access to.

In addition to the statewide efforts, LifeBridge Health utilized the COVID-19 Susceptibility Index to strengthen the launch of its community mobile health clinics. This “on the ground” approach provides access to medical and social services for people who may face multiple barriers to care. In the first six weeks after launch, the community mobile health team saw over 300 high risk individuals. Over half suffered from more than three underlying chronic conditions but had not seen their primary care provider for active issues due to underlying social needs. The LifeBridge team was able to provide onsite medical and social care, including COVID-19 testing, and establish a path to help people improve access to ongoing care. Based on the success of this initial effort, the community mobile health clinic has expanded efforts to improve pediatric immunization rates, community flu vaccination, and assistance for elderly populations in low income or congregate housing.

Large volumes of risk data are only valuable to healthcare organizations when they are analyzed in a fashion that results in actionable insights. In an interview with the American Journal of Managed Care, Dr. Mani stressed the importance of being able to stratify risk so health leaders can disseminate critical information at a neighborhood level and then down to the individual level. This enables healthcare providers to establish trust within the community, optimize preventative treatment and measures, and improve health outcomes within often-underserved populations.

To learn more about the SocialScape platform, and how it provides visibility into the social risk impacting an entire population, visit

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