Several states are taking steps to implement statewide or regional referral networks aimed at better coordinating health care and social services to address social needs

Additional Examples

Additional examples of this work are highlighted below:

  • ASPE Report on Community-Level Efforts to Address SDOH – A recent report from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) included a landscape review of community-level efforts to address SDOH, followed by interviews with participants in three community-level initiatives that have built networks to coordinate clinical and social services: 1) The GRACE Network, which builds the cross-sector partnerships necessary to fully address the needs of individuals experiencing homelessness in Grand Rapids, MI; 2) Healthy Together, which convenes a coordinated network to eliminate siloes and bring together partners to address food, housing, and transportation; and 3) United Community, convened by Kentucky’s Metro United Way to improve the processes and systems available for addressing social needs.
  • NCCARE360 – An example of this work is currently underway in North Carolina, where a public-private partnership of state government, the United Way, private foundations, and tech vendors have developed NCCARE360 — which connects community-based organizations (CBOs) and the state’s health system. NCCARE360 leverages partnerships that provide expertise in building the following components of the network:
    • A statewide resource directory which includes a call center with dedicated navigators, a data team verifying resources, and text and chat capabilities.
    • A community data repository that integrates multiple resource directories across the state and allows data sharing. The model will be extended to manage resources specific to the social determinants of health in North Carolina.
    • A shared technology platform that enables health and human services providers, community-based organizations, and others to send and receive electronic referrals, communicate in real-time, securely share client information, and track outcomes.
  • MyFloridaMyFamily – The Florida Department of Children and Families (DCF) is using MyFloridaMyFamily to prevent families from coming into crisis by connecting them to the services they need, when they need them. Staff across the department, including in the Family Safety and Preservation, Economic Self-Sufficiency, and Substance Abuse and Mental Health divisions, use the findhelp platform to identify resources and make connections for Florida families. Since the site launched in August 2020, over 900,000 users have visited DCF’s platforms, resulting in over 420,000 connections to 18,000 social care programs.
  • Connecticut Hospital Association – Another example of this important work has started in Connecticut, where the Connecticut Hospital Association and its member systems are working with CBOs on a statewide coordinated care network of health and social service providers to deliver integrated care. The network uses a technology platform to better connect patients to local service agencies that help with housing, food, transportation, and employment services. This new statewide coordinated network:
    • Allows health providers and CBOs to send and receive secure referrals to connect individuals to services to address social needs.
    • Partners with 211 Connecticut, a program of the United Way of Connecticut and the state’s primary resource and referral platform, to connect to 211’s database of more than 4,000 CBOs.
    • Pilots at some Connecticut hospitals already are strengthening care coordination with local social service organizations, seeing positive results for patients, community organizations, and care providers.
  • San Diego 2-1-1San Diego 2-1-1 is a highly regarded resource and information hub that connects people with community, health and disaster services and which works in collaboration with Live Well San Diego, a program that aligns efforts across sectors to improve the lives and health of San Diego County residents. San Diego 2-1-1 also established a Community Information Exchange (CIE) Network that provides an integrated technology platform to coordinate care and share information.
  • Ohio Pathways Community HUB – The Ohio Pathways Community HUB model is used as a strategy to identify and address risk factors at the individual and community levels through collected data, providing a centralized process, system and resources to track services and tie service payment to the outcomes through centralized Care Coordination System (CSS). The model utilizes a network of CCAs who employ trained Community Care Coordinators to help at-risk patients navigate the health and social services resources in Summit County, Ohio.