Ready to Bring Healthcare Home?
Empower your nursing teams, reduce health disparities, and strengthen family wellness with a digital solution designed for community-based care.
What Is Huddy Health Community?
Built on Huddy Health’s foundational architecture, Huddy Health Community is a digital suite focused on novel community and family based models of prevention and treatment service delivery for families—particularly those in Medicaid or other managed care populations. Designed in conjunction with a leading nursing research university, it serves as a bridge between clinical care and community-based support, ensuring that nurses can recruit, evaluate, and intervene effectively in patients’ home or local environments.
Huddy Health Community in Action:
Safe Families: Community Screening & Linkage to Prevent Overdose >>>
This SAMHSA-sponsored research is evaluating the efficacy of a nurse-driven, multi-level, Community Screening and Linkage to Substance Use Services program in Mott Haven, NYC. Mott Haven—one of the hardest hit localities by the overdose epidemic and the poorest congressional district in the continental US—representing a high-need community and the catchment area for the current project. With substance use-related emergency room visits and hospitalizations about three times as high as the New York City-wide average, Mott Haven residents face substantial challenges with the adverse consequences of untreated alcohol and drug misuse in their community. The right to access high-quality and affordable substance use and mental health-specific treatment and prevention services are core components of an effective community response. This access is too often not a reality for Mott Haven families. The project addresses this gap head on through a community-based screening, brief intervention, and referral to services (SBIRT) model, combined with multi-sectoral collective action among families, health, and social service providers to enhance substance use outcomes and care integration. A particularly innovative aspect of Safe Families is the integration of state-of-the-art care management tech to achieve scalability of its highly locationally flexible, community-based approach to substance use services. In this domain, CLAFH collaborates with Huddy Health, our health tech partner, to leverage the latest substance use treatment and prevention digital platform to optimize recruitment, engagement and delivery of services to families.
Community Specific Advantages
- Streamlined Recruitment: Identify and onboard families in need of the defined interventions.
Evaluation: Leverage digital assessments to monitor effectiveness of delivery.
- Evaluation & Continuous Improvement: Use digital assessments to track the effectiveness of services, adjust protocols as needed, and demonstrate measurable impact.
- Targeted Interventions & Education: Allows for the definition of intervention protocols and their delivery by multiple types of workers including nurses, health aides and other supporting community workers.
- Improved Outcomes & Reduced Costs: Early detection of health risks through early intervention and evaluation can lower hospital admissions and readmissions, ultimately saving on healthcare costs.
- Scalable Family-Based Care Delivery: Includes the ability to schedule diverse types of workers with families that require their services.
- Support for Value-Based Care: Data-driven insights on member progress, outcomes, and engagement facilitate quality reporting and reimbursements tied to performance metrics available via APIs.
How It Works
- Identify & Enroll: Nurses or community workers easily onboard families needing specific interventions.
- Define, administer and track delivery of intervention protocols: Define the protocol to be delivered and capture worker notes and checklists about the delivery.
- Define, administer and evaluate: Evaluate families and family members at the start, in the middle, and at the end of care delivery
- Manage worker and family schedules: Coordinate appointments and schedules with families, family members, and care team members.
- Implement patient-facing tools: Huddy can build facing patient content-delivery and communication tools branded to your organization.
Why It Matters
- Improved Outcomes & Reduced Costs: Early detection of health risks through early intervention and evaluation can lower hospital admissions and readmissions, ultimately saving on healthcare costs.
- Enhanced Member Engagement: By providing intuitive tools and resources directly to families, Huddy Health promotes better adherence to care plans.
Scalable Care - Coordination: The platform’s flexible workflows and alerts allow care managers to oversee larger populations while still delivering personalized support.
- Support for Value-Based Care: Data-driven insights on member progress, outcomes, and engagement facilitate quality reporting and reimbursements tied to performance metrics.
Empower Your Community
Transform your approach to community-based healthcare with Huddy Health Community. Enabling prevention-focused interventions and holistic support for families—particularly those in Medicaid or managed care populations.