A targeted, data-driven engagement model successfully connects hard-to-reach members with primary care, improving outcomes and reducing costs.
The challenge
A national health plan faced gaps in member engagement with primary care, following In-Home Health Evaluations (IHE) resulting in unaddressed care concerns.
Barriers included:
- Some members lacked an established primary care provider (PCP) relationship while others were uncertain about how to schedule or access primary care services.
- Social drivers of health affected consistent follow-through, and outreach fatigue in a large-scale health plan was a concern.
- Fragmentation between findings and clinic-based care delayed follow-up. Strengthening PCP engagement was a strategic priority to support continuity of care, preventive service utilization and member experience to improve member outcomes and better contain costs.
The opportunity
By leveraging insights from IHEs, the health plan had an unmet opportunity to help connect hard-to-reach members with primary care, close care gaps and improve continuity while minimizing outreach fatigue by:
- Using IHE data to identify members without a PCP or with unconfirmed PCP relationships.
- Translating clinical and social insights into coordinated follow-up actions while minimizing potential member abrasion.
- Supporting vulnerable members in navigating access barriers and improving alignment between IHEs and longitudinal care management.
The solution
Signify Health deployed a targeted, data-driven engagement model to connect hard-to-reach members and address the challenges experienced by the health plan by:
- Identifying members without a PCP or confirmed existing PCP relationships and providing hands-on support for appointment scheduling.
- Delivering personalized, data-driven outreach informed by clinical, social and behavioral insights from IHEs.
- Coordinating follow-up care, including preventive screenings, immunizations, behavioral health support and medication management.
- Tailoring engagement strategies to individuals needs, considering health literacy, medication adherence, financial strain and social drivers of health while minimizing member abrasion.
The results
Successful engagement of hard-to-reach members at scale, delivering measurable improvements in primary care access, member satisfaction and quality outcomes.
- 13,026 previously disconnected members were identified for outreach and 5,978 members were successfully contacted.
- A 16.4 percent conversion rate surpassed average enterprise benchmarks (10 percent–12 percent), which demonstrated that even hard-to-reach members can be effectively engaged at enterprise scale.
- Net promoter score (NPS) of 73, well above the industry standard, helped improve member satisfaction through trust-building and personalized guidance.
Personalized, data-driven outreach can bridge gaps in primary care access, even for hard-to-reach members. Signify Health’s approach demonstrates that meaningful engagement at enterprise level is possible without creating member fatigue or undermining trust all while delivering measurable outcomes, stronger member relationships, cost savings and improved quality scores.
Key benefits to the health plan
- Strengthened primary care alignment for members who were previously disconnected.
- Supported quality measure performance and CMS Star Ratings|HEDIS® metrics.
- Improved member satisfaction through trust-building and hands-on guidance.
- Demonstrated that even hard-to-reach members can be effectively engaged at enterprise scale.
To learn more, visit signifyhealth.com/health-plans/carecoordination-pathways.