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Social determinants of health in West Virginia


  • Social and economic factors, including economic instability, food insecurity, and unsafe housing, have a major impact on health.

  • People facing these challenges are often enrolled in Medicaid and other health and human services programs. In West Virginia, one-third of the population is on Medicaid.

  • These citizens see community-based organizations (CBOs) as trusted partners in solving their social determinants of health (SDOH) needs. However, services are often delivered in a fragmented, uncoordinated way, leaving needs unmet.    


Prove the effectiveness of addressing SDOH by identifying the needs of at-risk people, coordinating services, and improving health outcomes. 


Beginning in 2018, West Virginia teamed with us to pilot an SDOH data capture, evaluation, and outreach project across two large counties. Leveraging our enrollment broker infrastructure in the state, we developed a full SDOH survey and added it to the Medicaid enrollment process. It revealed 2.5 unmet needs on average.   

To address these needs, Maximus managed extensive outreach to Medicaid members. Plus, we built a referral network of CBOs to streamline delivery of services. Of the 4,000 CBOs in our system statewide, we actively engaged 160 in this pilot. 

By connecting families to services such as child care and transportation, we’ve made it easier for people to see doctors, helping the state meet its goal of increasing preventive care visits and boosting overall health. 

Image of the case study graphic for west virginia

How we did it

Taking a holistic view of Medicaid members’ circumstances, we created a comprehensive program to address SDOH needs — largely at the height of the pandemic. Some keys to success:  

  • Our Center for Health Literacy ensured the survey was targeted to audience level
  • A multichannel campaign (mail, phone, web) led to a high rate of response  
  • Data aggregation and analysis with our partner Signify Health provided meaningful insight into member history and SDOH needs
  • Engagement coordinators earned the trust of a population wary of state agencies, coached them through the process, made referrals, and followed up to ensure completion  
  • Development of a single network with a common platform eased the burden on CBOs, who no longer had to coordinate with multiple managed care organizations
  • Technology and data integration streamlined processes, simplified referrals, and made it easy to track successful interventions  


95,982 contacts
made in total

52,091 assessments
for SDOH completed

122,629 needs
identified and verified

160 CBOs
engaged to provide services

Using SDOH to reduce costs and improve health outcomes   

A guiding principle behind SDOH is it costs less to prevent disease than treat it. By being smart about matching up SDOH with at-risk people, states can save millions on Medicaid or acute care costs.   
Implementation is flexible, too. For example, states can conduct SDOH surveys and outreach together to avoid a lag in services. Or choose a phased approach, county by county, to prove efficacy before a larger roll-out.