2023 Cohort

Infrastructure & Data Tools

2023 Cohort Findings


The 2023 social determinants of health application had six opportunity areas for organizations to choose from in their response to how their solutions would address health-related social needs. Solutions were expected to focus on one or more aspects of the social needs challenges within this opportunity.

The second 2023 showcase highlighted solutions that address at least one of the following two focus areas:

  1. Transportation Services
  2. Infrastructure and Data Tools for Providers, Plans, and States for Social Determinants of Health Management

Transportation Services

Current Challenges

Many individuals and families struggle with reliable transportation options, as they either do not have a vehicle or permit or their cars are older and need costly maintenance and repairs. Individuals often share a car with family members or friends, which can be challenging to coordinate. This can be even more challenging for people in rural communities who do not have access to reliable and timely public transportation. Without reliable transportation, individuals struggle with getting to work, health care appointments, or other important activities.

Innovation Opportunities

Solutions should provide individuals and families with the flexibility to schedule rides or shuttles to help them get to and from their work, school, or health-related appointments. Solutions could offset costs of ridesharing options or provide subsidies for gas or bus fare. Solutions should work in both rural and urban settings.

Infrastructure and Data Tools for Providers, Plans, and States for Social Determinants of Health Management

Current Challenges

For many state Medicaid programs and their managed care plans, it can be difficult to understand the extent of health-related social needs for Medicaid enrollees in their state. This makes it difficult to plan resources, create appropriate policies and programs, and support members to get their needs met. There is a great deal of infrastructure needed to assess and identify health-related social needs at an individual and aggregate level, connect people to the appropriate resources to address their needs, and ensure care teams have the information needed to address these needs,both in health systems and in community and governmental organizations.

Innovation Opportunities

Solutions should help state Medicaid programs and managed care plans build the data systems and tools to be able to identify and track social needs at an individual and population level, analyze the data as needed for care provision and strategy, ensure care teams have the information to enable members receive services across the continuum of care, including within the community, and to enable different entities to easily exchange information to increase coordination and integration of services.

Showcase: Infrastructure & Data Tools

Opening Remarks

Solutions Selected to Present

With criteria based on the findings from community discovery, members of the Selection Committee nominated the following organizations to present their models at the Infrastructure & Data Tools Showcase in June 2023.

Benefits Data Trust

Benefits Data Trust (BDT) is a national nonprofit, founded in 2005, that harnesses the power of data, technology, and policy to provide efficient and dignified access to public benefit programs, improving people’s health and financial security. Together with a national network of government agencies, healthcare entities, and other partners, BDT streamlines public benefits systems and directly connect eligible families and individuals to assistance. Since 2005, BDT has submitted over 1.2 million public benefit applications on behalf of individuals and families.


CareAdvisors provides a social care management software platform for Medicaid plans to engage hard-to-reach members struggling with social barriers. Through its software platform, CareAdvisors automates new enrollment and renewals for government benefit programs including Medicaid, Cash Assistance and SNAP. Its platform also supports access to local community-based social services including housing and food security resources through network partners.

Ready Computing

Ready Computing is a full-service IT consulting firm specializing in data-centric technology solutions for clients worldwide. Ready Computing serves as a trusted advisor and partner to private and public-sector organizations, health systems, health plans, community-based organizations, and government agencies to deliver insight and solutions from their data to improve patient and resident outcomes and the overall quality of service delivery. Ready’s SDOH solution, Channels 360, was developed to digitally connect, implement, and scale out customers’ vision for their system of care. This framework enables consolidation and sharing of necessary data across the spectrum of care to enrollees and their families. Channels 360 is capable of connecting health plans and human service providers to your model of care—including housing, wellness programs, self-care management, transportation, bereavement, and educational programs.

Unite Us

Unite Us is cross-sector collaboration software that builds connected communities through shared technology and local boots-on-ground community approach to address whole-person health needs. Unite Us breaks down communication, gaps in services, and data silos between government, healthcare, and communities with electronic referral care coordination, client management, and an outcomes tracking platform for efficient and effective "last mile" of social care delivery for wraparound supportive social services to improve population health.

Kaizen Health

Kaizen Health addresses the social determinants of health (SDOH) by removing transportation as a barrier to living a healthy and happy life and enabling greater access to fundamental resources like healthcare, food, education, employment, and housing. Kaizen Health pairs an adaptive and scalable technology platform with a nationwide infrastructure of transportation and delivery partners to serve urban and rural areas for people of all physical and mental abilities. Kaizen Health's innovative solution is utilized by some of the largest healthcare organizations, non-profits, municipalities, and public-school districts serving millions of individuals across the US.

Over 100 SDOH solutions applied to MIC’s 2023 Cohort

Read the full roster of SDOH applicants.