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Key Takeaways:
- Unmet basic needs such as social determinants of health (SDOH) impede medication adherence, chronic disease control, and appointment attendance, lowering performance on blood pressure control, diabetes A1c, kidney health evaluation, hypertension management, medication adherence (triple weighted), and all-plan readmissions measures.
- Interventions such as medically tailored meals, food delivery, transportation support, and closed-loop referrals stabilize clinical parameters, improve adherence, and strengthen visit completion when integrated into care-management workflows, resulting in measurable gains across Star Ratings.
- Interoperable infrastructure with real-time referral tracking and unified platforms reduces data silos, enhances coordination with community partners, and supports the timely, documented service delivery required for the Centers of Medicare & Medicaid Services (CMS) health-equity expectations and value-based performance.