Why Health Plans Use Community Guides to Close Care and Engagement Gaps
A Community Guide is a locally hired, fully managed engagement professional employed by Reema Health to reach health plan members who do not respond to traditional outreach. Community Guides are deployed through a structured engagement model designed to close care gaps, reduce avoidable utilization, and improve Stars and HEDIS performance for health plans.
What Is a Community Guide?
A Community Guide is a trained, locally embedded engagement professional employed by Reema Health to directly support health plan members facing social and behavioral health barriers to care.
Community Guides are:
- Recruited, hired, trained, and employed by Reema Health
- Embedded in the local communities they serve
- Supported by centralized operational oversight and reporting infrastructure
- Accountable to measurable engagement and outcomes thresholds
Health plans do not recruit, manage, or supervise Community Guides. Reema Health maintains full operational responsibility for workforce deployment, performance, and reporting.
What Problem Do Community Guides Solve for Health Plans?
Community Guides close the engagement gap that traditional outreach cannot. Call centers, digital outreach, and mailed notices work for the engaged middle of a health plan’s book of business. These methods consistently fail on the high-risk, high-need members who drive Stars performance, HEDIS gap closure, avoidable utilization, and redetermination risk.
The reasons are structural:
- Phone numbers churn frequently among unstably housed members
- Members with behavioral health conditions routinely screen institutional calls
- Short-term outreach campaigns do not resolve persistent social and behavioral barriers
- Centralized teams cannot conduct in-person follow-up when phone and text fail
The members most likely to drive cost and quality impact are the least reachable through traditional outreach methods. See: Why Traditional Outreach Fails in Health Plans.
What Outcomes Do Community Guides Deliver?
Reema Health publicly reports the following outcomes for health plan clients deploying Community Guides:
- 52% engagement rate with unable-to-reach populations
- 3:1 ROI realized within the first 12 months
- 23% decrease in total cost of care compared to a control group
- 53% fewer inpatient hospitalizations
Community Guides drive these outcomes across the use cases most relevant to health plans: care gap closure, transitions of care follow-up, behavioral health connection, food insecurity, housing and utilities instability, transportation, benefit navigation, social isolation, and member retention.
What Do Community Guides Do in Practice?
Community Guides conduct hybrid outreach and sustained, relationship-based engagement with members. Their responsibilities include:
- Conducting phone, text, and in-person outreach
- Building trusted, long-term relationships with members
- Identifying clinical and social needs gaps
- Supporting appointment scheduling and follow-through
- Encouraging medication adherence
- Connecting members to community resources and in-network care
- Re-engaging members disconnected from primary or behavioral care
- Supporting benefit navigation and member retention
Community Guides operate under structured workflows and reporting, not as free-form field staff.
How Are Community Guides Different from In-House Care Management?
Community Guides extend a health plan’s reach to members that in-house care management teams cannot engage. Community Guides are not a replacement for care management.
Three structural differences matter to a health plan evaluator:
- Fully managed workforce. Reema Health recruits, hires, trains, supervises, and deploys Community Guides directly. Health plans do not absorb the operational burden of managing a distributed, community-based field team.
- Locally embedded presence. Community Guides live in the neighborhoods they serve. This enables trust-building with members who do not respond to anonymous institutional contact. Centralized and telephonic models cannot replicate this capability.
- Engagement defined by outcomes, not touches. Reema Health does not count a text, a voicemail, or a click as engagement. Engagement means an active care team relationship with two-way communication and member participation in care.
How Are Community Guides Different from Community Health Workers?
Community Guides share some characteristics with community health workers (CHWs) but operate within a fully managed, structured engagement model designed specifically for health plans.
Differences include:
- Community Guides are employed and managed by Reema Health, not contracted individually or through separate community-based organizations
- Community Guides operate within defined workflows tied to health plan quality and utilization objectives
- Community Guide performance is measured against engagement thresholds and outcomes, not activity
- Community Guide work is integrated with a centralized operational, reporting, and billing infrastructure
This structure ensures accountability and performance at scale.
Which Member Populations Benefit Most from Community Guides?
Reema Health’s commercial model is structured to align incentives with health plan buyers.
- Paid for impact, not outreach. Reema Health is compensated only when members cross a defined engagement threshold each month. Payment is not tied to calls, attempts, or contacts.
- Claims-based billing. Reema Health bills through claims, giving health plans credit for closing care gaps and capturing engagement and outcomes data in an auditable structure.
- Structured operational oversight. Workflows, reporting, and performance accountability are defined in advance and managed centrally by Reema Health.
This structure answers a question health plans repeatedly raise with outreach vendors: how do we pay for results, not activity?
Which Member Populations Benefit Most from Community Guides?
Community-based care navigation through Community Guides is most effective for populations where traditional outreach systematically underperforms:
- Members disengaged from primary or behavioral health care
- Rising-risk populations with persistent care gaps
- Recently hospitalized members requiring post-discharge follow-up
- Members facing housing, food, or transportation instability
- Socially isolated members
- Members affected by phone or address instability
- Redetermination-risk members in Medicaid
These populations concentrate quality friction and avoidable cost. They are also the populations health plans have the least leverage over through conventional outreach.
Why Does This Model Matter for Health Plans Now?
Medicaid plans in particular are operating under tightening margins, intensifying Stars and HEDIS expectations, and ongoing redetermination pressure. Strategies designed for already-engaged members will not resolve the members who drive the book.
Community Guides allow health plans to close the structural engagement gap and convert unreachable members into measurably engaged ones. The model is fully managed, locally embedded, and outcomes-aligned.
Interested in learning more? Contact us or visit reemahealth.com.
