Closing the Care Gap: Tackling SDOH to Help Medicaid Members Thrive

Imagine a single mom in rural Missouri who needs dialysis three times a week. But the nearest clinic is 45 miles away and the bus schedule doesn’t line up with her shift. Or an aging grandfather who can’t get to the grocery store for fresh produce, so he relies on whatever’s in the pantry. These aren’t rare stories. They’re daily realities for millions of Medicaid members, and they’re driven by something far bigger than a missed appointment: social determinants of health (SDOH).

SDOH are the conditions in which people are born, live, work, learn, and age. Things like access to nutritious food, stable housing, reliable transportation, education, and social connections. According to the Robert Wood Johnson Foundation, these non-medical factors influence up to 80% of health outcomes, often outweighing clinical care alone. When SDOH create barriers, even the best medical plans fall short. Chronic conditions worsen, preventable hospitalizations rise, and entire families pay the price in lost wages, isolation, and poorer quality of life.

At MTM Health, we don’t just recognize these gaps. We close them. Through innovative, person-centered solutions, we’re helping Medicaid members nationwide move from survival mode to thriving. Here’s how.

The Hidden Costs of SDOH Barriers

Let’s break down three of the most common (and impactful) SDOH barriers:

• Food Insecurity: Without reliable access to groceries or meal deliveries, members struggle to manage diabetes, heart disease, or even basic nutrition. Poor diet choices lead to complications that drive up emergency room visits and long-term costs.
• Housing Instability: Unstable or unsafe housing makes it hard to rest, recover, or even store medications properly. For aging members, it can mean choosing between paying rent and affording home modifications that allow them to age in place.
• Transportation Barriers: This is often the silent disruptor. Nearly four million Americans miss or delay care each year simply because they can’t get there. Without rides to important appointments, therapies, or the pharmacy, members fall out of care entirely, leading to higher rates of chronic disease progression, avoidable inpatient stays, and skyrocketing healthcare expenses.

These aren’t isolated issues. They compound. A missed dialysis trip can land someone in the hospital. Food insecurity can worsen mental health. Housing instability plus transportation gaps can trap families in cycles of poverty and poor health. For Medicaid members—who are traditionally disproportionately affected by low income, rural living, and disabilities—these barriers create massive care gaps that traditional healthcare often overlooks.

MTM Health’s SDOH Solutions: Practical, Scalable, and Member-Focused

MTM Health has spent more than 30 years building a nationwide network that treats transportation as an essential part of care—not an afterthought. Three of our core solutions work together to remove barriers and empower members to live fuller, healthier lives.

1. NEMT: More Than Just Medical Rides

Non-emergency medical transportation (NEMT) is our foundation. Since 1995, we have coordinated safe, reliable rides for Medicaid and Medicare members to doctor visits, dialysis, therapy, and behavioral health appointments using sedans, wheelchair-accessible vehicles, rideshare, public transit, and more.

But we go beyond just transportation to health care further. In some markets, we partner with health plans to cover non-medical trips too: grocery runs for fresh food, pharmacy stops, job interviews, family events, and community activities. These rides combat isolation, support financial stability, and address food and housing-related SDOH head-on.

Every year, we provide more than 35 million trips nationwide. Our proprietary MTM Link platform uses real-time GPS tracking, predictive analytics, AI fraud detection, and member-friendly apps to improve the transportation experience, deliver 95%+ customer satisfaction, and reduce costs by up to 25% compared to unmanaged programs. Fewer missed appointments mean better chronic disease management, lower inpatient costs, and improved HEDIS, STAR, and CAHPS scores for health plans.

In short, NEMT turns “I can’t get there” into “I’m on my way.”

2. HCBS: Supporting Independence at Home and in the Community

Home and community-based services (HCBS) take care beyond the clinic walls. MTM Health works with health plans to coordinate specialized therapies—equine, pet, art, music, and aquatic—that help members with intellectual/developmental disabilities, behavioral health needs, trauma, or chronic conditions rebuild confidence, social skills, and physical mobility.

These aren’t luxuries. They directly tackle SDOH by reducing loneliness, improving emotional regulation, and promoting community integration. A member who once could only walk 20 feet now walks 200 after equine therapy. Another who felt isolated lights up during pet therapy. We help health plans manage this service by coordinating therapy provider networks, onboarding, billing, and more in states like Texas, Florida, and Missouri. By integrating HCBS with NEMT rides, we ensure members can actually get to these life-changing services, closing gaps in housing stability, social connection, and daily wellbeing.

3. Wanda: Empowering Caregivers and Aging in Place

For older adults who don’t receive NEMT benefits through Medicaid or Medicare, our Wanda platform is a game-changer. This direct-to-consumer platform available in St. Louis, Tucson, and Phoenix connects caregivers with vetted drivers for rides anywhere in their community. Doctor’s appointments, grocery store runs, visits to friends and family, outings to local community centers, and more are all within arm’s reach with Wanda.

Wanda alleviates the caregiver burden by helping families avoid sacrificing work hours or income while ensuring loved ones stay safe and independent at home. It directly addresses transportation barriers, letting seniors and people with disabilities age in place with dignity instead of facing institutionalization.

The Bigger Picture: Nationwide Impact and Real Thriving

The results MTM Health can deliver to our clients and members is transformative:

• Better Health Outcomes: Members stay connected to care, nutrition, and community, reducing complications and ER visits.
• Cost Savings: Health plans see lower overall spending because preventive, community-based support replaces expensive reactive care.
• Equity and Independence: Medicaid members across rural and urban America gain the tools to thrive, not just survive—whether that means landing a job, managing a chronic condition, or simply enjoying time with family.

Ready to Close the Gap Together?

Social determinants of health aren’t abstract policy terms. They’re the real-life hurdles standing between people and better health. At MTM Health, we believe closing those gaps isn’t just possible; it’s our mission.

By offering NEMT, HCBS, and Wanda services with compassionate, technology-powered coordination, we’re helping Medicaid members nationwide access the care, resources, and connections they deserve. The result? Healthier families, stronger communities, and a more sustainable healthcare system.

If your health plan is ready to tackle SDOH and deliver measurable results, let’s talk! Fill out the quick form below to connect with our team and learn more.