Improving Health Outcomes While Addressing Social Determinants

A 74-year-old diabetic with lung cancer living alone has severe mobility issues that prevent her from leaving the second floor of her home. She also suffered from lack of proper nutrition which impacted her health, and a lack of socialization that caused depression. Both the financial and social determinants of health were causing numerous preventable and unnecessary ED visits.

Member Results

  • Now compliant with medication and management of diseases due to increased health literacy
  • Has adequate nutrition resulting in better health management
  • No longer has depression due to increased socialization
  • No ER / IP visits during the 6 months working with a PHN
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How Conifer’s Personal Health Nurse (PHN) Helped
  • Personal Health Nurse coordinated with providers for medical issues
  • Member enrolled in PACE for socialization needs
  • Nurse utilized local resources found on various sites (, Aunt Bertha, etc) to coordinate meal delivery
  • Local charity group enlisted to install stair rider for member to transport to multiple levels of home
  • Frequent calls from nurse for health literacy education, support and reassessment
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Individualized Approach
Personal. Health. Nurse.

Help members navigate the care continuum to find the right care, in the right setting, at the right time —go beyond episodic case management or chronic disease management.

Our Personal Health Nurses engage members and optimize benefit plan utilization through collaborative care management and heightened health literacy.

Conifer Health’s Population Health Management solutions are powered by ConiferCore® technology, a proprietary platform for:

Member Advocacy

Care Navigation

Dedicated one-on-one collaboration and care planning with a Registered Nurse

Disease Management

Goal-based programs care for the person, not just the chronic condition

Case Management

Support members most at-risk for high-dollar or ineffective benefit utilization

Utilization Management

Maximize member access to the right care, in the right setting, at the right time

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