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Iowa’s Title V Program performs its 7 millionth intervention addressing the social determinants of health

By Signify Health News on 11/12/20 7:00 AM

A statewide initiative to address the social determinants of health (SDOH), which was developed in partnership between the Iowa Department of Public Health and Signify Health, announces a major milestone in its effort to improve outcomes and access to care for Iowa mothers and their children.

DALLAS and DES MOINES, November 12, 2020 — The Iowa Department of Public Health (IDPH), in partnership with Signify Health, a leading provider of technology-enabled healthcare solutions designed to keep people healthy and happy in their homes and communities, launched a statewide community network in 2017 to integrate social care with medical services. Today, that network has reached a tremendous milestone by performing its 7 millionth SDOH activity on behalf of more than 835,000 Iowa residents.

The Iowa statewide community network is composed of a virtual care team of healthcare and social service partners. Today, the network spans the state’s 99 counties and collectively manages six Title V programs, with a shared technology platform that enables community providers to safely share information, coordinate services, and connect members to non-medical needs like transportation, housing, health management, and more.

The 7 million SDOH-related activities include SDOH assessments, care coordination, interagency referrals, and care gap closure services such as immunizations, well-child visits, medical home identification, health insurance access and eligibility, and more.

For example, under the program the percentage of members receiving a regular source of obstetrical care increased from 67% in 2017 to 97% in 2019. In addition, the program resolved more than 1,400 cases related to member mental health challenges, including depression, anxiety, and trauma. More than 395,000 of the more than 835,000 members were identified as having SDOH needs.

“This innovative program and partnership is connecting health and human services like never before, providing a healthier start at life for thousands of children,” said Marcus Johnson-Miller, CPM, Title V Director and Bureau Chief, Bureau of Family Health at IDPH. “We’re building a healthier Iowa by enabling community collaboration in a way that respects the dignity and privacy protections of our members—all to support the lives and outcomes of pregnant mothers through early child development."

Cross-sector collaboration was made possible by Signify Health’s privacy-enabled technology platform, which allows participating organizations to safely share information within a formalized legal structure, managing members’ whole-health needs longitudinally across care settings. Additionally, this platform replaced IDPH’s historically fragmented data collection processes, uniting all incoming data sources into a single system for real-time outcomes reporting to demonstrate program improvements, care gap closure, and SDOH resolution.

“IDPH is proving that SDOH can be identified and addressed at scale, with a strong team of health and community partners working together to sustainably improve outcomes,” said Kyle Armbrester, CEO of Signify Health. “We are honored to be working with such a forward-thinking partner committed to reshaping the future of whole-person care.”

About Signify Health
Signify Health is a leading provider of technology-enabled healthcare solutions designed to keep people healthy and happy at home. We are accelerating the movement to value-based care by working with payers and providers to address both the financing and delivery of care, and sharing accountability for driving better outcomes for the individuals and families we serve. Our innovative episodes of care payment models and personalized health assessment and care coordination services enable us to close clinical and social care gaps, manage risk and drive a better experience for millions of people each year. Applying powerful analytics and clinical expertise, we support individuals’ health journeys from the acute care facility to the ideal next site of care and all the way to a place of residence, helping people get home sooner and stay there longer. We support care needs anywhere in the U.S. through our high-performance provider and community networks – including the nation’s largest field-based network of doctors and nurse practitioners trained and ready for in-home visits. For more information on how we are taking health homeward, visit us at

Topics: SDOH