Candace Stohs-Krause, Author at Findhelp

No Wrong Door is a podcast that explores how social care delivery is evolving to better support whole person care. Hosted by Findhelp VP of Marketing Amy Gordona, the series features conversations with social care experts, healthcare and government innovators, and Findhelp leaders who are shaping the future of access, coordination, and connected care.

Each episode offers an inside look at the systems, decisions, and ideas driving change—and what it takes to build a social safety net that works at scale.

'No Wrong Door' is a podcast from Findhelp exploring how social care delivery is evolving to better support whole-person care.

Live from the Texas Social Care Summit, this special episode of No Wrong Door takes us out into the wild with Alex Reed, Division Manager of Community Health at Denton County Public Health.

Denton County recently took home the 2025 Model Practice Award from the National Association of County and City Health Officials (NACCHO)—and for good reason. Alongside host Amy Gordona, Alex breaks down the recipe behind Denton’s highly successful, cross-governmental, community-wide rollout of their Findhelp network, proving that true social care transformation requires a mix of proper digital infrastructure, raw data, and a whole lot of patience.

In this episode, we explore:

Moving past “sticky note technology”: How Denton County transitioned away from bulky physical binders and outdated print resource directories toward a unified digital referral ecosystem.

Fostering true community ownership: Why the City of Denton and Denton County intentionally removed corporate and governmental branding from their platform to ensure local non-profits felt equal ownership.

The power of a slow-baked launch: Why rushing a technology deployment can cause a network to fracture, and how 11 weeks of intentional, hands-on partner onboarding made all the difference.

Watch episode 9: “Creating Connected Communities”

Key themes from the conversation

Building an integrated social care ecosystem takes far more than just launching new software—it requires cultural buy-in, radical cross-agency trust, and a deep respect for the boots-on-the-ground practitioners. In this episode, Alex maps out the core philosophies and practical strategies that helped Denton County move away from fragmented workflows and build a unified, award-winning care network.

Retiring the resource binder

For decades, social workers have relied on heavily bookmarked, manually updated binders to connect residents with food, housing, and healthcare.

If a point of contact leaves an agency, that hard-earned relationship breaks, leaving care navigators scrambling and patients falling through the cracks.

Alex highlights how building a shared, digital infrastructure finally allows case managers to close the loop, track outcomes, and sleep a little easier at night.

“Whenever someone came to me and said, ‘Hey, I have a three-year-old concerned about food security. I need to know who to reach out to.’ I would take this [binder], open it, and go to the food resources section. And then there would be like someone’s name that I had crossed out because they used to be my point of contact, and now they don’t work there any longer… Now, we have very advanced technology.”

Alex Reed

Division Manager of Community Health

Denton County Public Health

Cultivating radical collaboration and community ownership

Cross-governmental initiatives often stall due to territorial budget battles or competing political agendas. Denton County and the City of Denton bypassed this entirely by letting go of individual branding.

By creating a neutrally designed platform, they positioned the network as a public square belonging to the community rather than a strict county or city program, driving massive adoption among local community-based organizations (CBOs).

“Let’s let the community own Findhelp. It doesn’t belong to the City of Denton. It doesn’t belong to Denton County. Let’s let the community own it.”

Alex Reed

Division Manager of Community Health

Denton County Public Health

The art of “slow baking” community & CBO engagement

Implementing new technology is exciting, but forcing an overnight launch often alienates community partners who are already stretched thin.

Denton spent 11 weeks strictly on partner preparation before going live:

Hosting local webinars
Helping agencies claim their programs
Mapping workflows

Taking the time to build trust ensures the network won’t crack under the weight of real-world demands.

“Don’t you dare open the oven before it’s ready. Give it time. Because I’m an impatient person, I think that it’s really easy to just jump two feet in, and at some point we do have to open the oven, right? But as you’re baking these tools into your community, listen to the community, wait for the dough to rise or the meringue to stiffen, and then open the oven whenever it’s ready.”

Alex Reed

Division Manager of Community Health

Denton County Public Health

Turning search analytics into tangible county public health resources

A closed-loop social care system provides more than just streamlined referrals; it generates hyper-local data that uncovers structural gaps.

In Denton County, Findhelp analytics revealed that over 50% of searches were specific to housing, exposing a massive discrepancy in available support.

This hard data now directly guides municipal conversations, grant applications, and even the physical deployment of mobile public health units to high-need areas.

“We didn’t have the data or visibility on the data set. So this has been really instrumental, even as a local public health department… when we’re sending out our mobile unit, we can look at the geographies where people are having a high search volume and send the mobile unit into those spaces.”

Alex Reed

Division Manager of Community Health

Denton County Public Health

Learn more about Denton County’s award-winning social care program

Connecting residents to the right social services at the right time is a critical challenge facing every growing community. In Texas, the City of Denton and Denton County Public Health acted as conveners, funding and facilitating a community-wide solution.

This case study details how this partnership, and collaboration with community service providers, led to the creation of a centralized resource hub that strengthens the entire network of care.

As a result of this work, Denton County was one of 19 local health departments nationwide to receive the Model Practices award in 2025.

How Denton County Created a Community-Wide Solution for Social Care

**What’s next for No Wrong Door?**

“Creating Connected Communities” is available now—Episode 10 will be released on June 24, 2026 and features Kraig Dalton, Findhelp’s Director of State Accounts, discussion the innovative implementation of the Tennessee Community Compass, the state’s social care platform.

Subscribe to No Wrong Door wherever you listen to podcasts to be notified when new episodes drop:

Across Pennsylvania, organizations are working to build a more connected approach to care, one that recognizes that health outcomes are shaped by far more than clinical services alone. At the Pennsylvania Social Care Summit, healthcare leaders, community-based organizations, health plans, state agencies, and social care advocates came together to discuss how technology, policy, and partnership can strengthen the systems that support people every day.

From Medicaid transformation and community health worker reimbursement to data sharing, care coordination, and CBO engagement, the conversations highlighted both the challenges and opportunities ahead.

While the topics varied, a common thread emerged throughout the day: creating a stronger social safety net requires shared infrastructure, trusted partnerships, and a commitment to putting people at the center of every decision.

Read on for key takeaways:

From PA Navigate to HIE partnerships, leaders are building a future where social care data is as connected as clinical data.

Upcoming policy changes to Medicaid and SNAP and new reimbursement pathways are reshaping the social safety net.

Sustainable progress depends on trusted partnerships and workflows that make it easier for people to get connected.

A special thank you to everyone who joined us and to our fantastic speakers for sharing their insight, experiences, and vision.

Highlights from the 2026 Pennsylvania Social Care Summit

This year’s Summit featured 74 participants representing government agencies, healthcare providers, community organizations, and more:

Below are some of the key themes and takeaways from a day of learning and sharing.

Pennsylvania’s smarter safety net

Opening the Summit, Findhelp COO Jaffer Traish shared a vision for the future of social care infrastructure and the role technology can play in helping communities connect people to support.

As Pennsylvania continues expanding its social care ecosystem, attendees discussed challenges ranging from digital access and program maintenance to referral outcomes and community health worker reimbursement.

Questions centered on how organizations can ensure residents without reliable internet access or digital literacy can still receive support, how program information remains current, and how care teams can better understand what happens after a referral is made.

The conversation highlighted a growing need for infrastructure that not only connects people to services, but also helps organizations understand outcomes and continuously improve care coordination.

Medicaid’s new frontier: Navigating the 2026 funding shifts

Keynote speaker Sally Kozak, State Medicaid Director, provided an in-depth look at significant federal policy changes affecting Medicaid, SNAP, and other public benefit programs. Sally emphasized the importance of communication, advocacy, and coordinated outreach to ensure eligible individuals maintain access to critical services.

Sally highlighted several areas where Pennsylvania continues to invest in community health, including Food is Medicine initiatives, housing supports, reentry programs, maternal health initiatives, and expanded opportunities for community health worker engagement.

The discussion focused on the operational realities organizations will face as eligibility requirements change, work requirements expand, and redetermination processes become more frequent. Attendees raised questions about emergency Medicaid eligibility, dual-eligible beneficiaries, CHIP coverage, caregiver exemptions, and how organizations can support residents navigating a changing policy environment.

“The unfortunate reality is some people have nowhere to go to get care. You need to lobby your local and federal representatives—many of them are unaware of the impact on the ground, versus what they’re hearing from the federal government.”

Sally Kozak

Medicaid Director

Pennsylvania Department of Human Services

Dignity by design: Leading with empathy

In the world of social services, fragmented processes and software aren’t just an administrative hurdle—they’re often the primary barrier between a person and the vital resources they need to survive.

For individuals in crisis, the process of managing documents and provider portals can be a source of trauma and inequity rather than a path to support.
For community organizations, the solutions are often too expensive, too complex, and require a significant time investment in training.

Phil Robinson, Findhelp’s Sr. Director of UX, explored how thoughtful design can improve access to social care services by reducing barriers and creating more supportive user experiences. The session focused on how empathy-driven design principles influence everything from navigation workflows to visual design choices, helping individuals feel more comfortable and confident when seeking help.

The discussion reinforced a broader Summit theme: Technology works best when it is designed around the people who use it.

“No wrong door” in action: Scaling PA Navigate through HIE collaboration

One of the most anticipated discussions of the day focused on the continued growth of PA Navigate and the role health information exchanges (HIEs), health systems, payers, and community organizations play in building a statewide social care network, through Findhelp’s Coalitions functionality. Panelists represented diverse organizations in the PA Navigate public-private partnership, including Jefferson Health, Penn Medicine, Pennsylvania’s HIE Consortium, the Community Action Association of Pennsylvania (CAAP), and UnitedHealthcare.

They discussed the challenges and opportunities associated with scaling adoption across Pennsylvania’s diverse healthcare landscape, and a recurring topic was integration. Healthcare organizations emphasized the importance of embedding social care workflows directly into existing clinical systems, reducing administrative burden and making it easier for providers to incorporate social care into everyday practice.

Attendees also discussed the critical role of change management, leadership support, and workflow design in driving adoption.

One question captured a challenge familiar to many organizations working to close the loop on referrals: “How many of you know that your patient got connected to help?”

Not a single hand was raised.

The moment underscored the need for stronger feedback loops, better data sharing, and greater visibility into outcomes.

The speakers also discussed Pennsylvania’s broader vision for connecting social care and healthcare data. Built on the state’s HIE infrastructure, PA Navigate aims to make social care information more accessible, reusable, and actionable across organizations while reducing duplication and improving coordination.

The long-term goal is ambitious but straightforward: make social care data as shareable and connected as medical data.

Learn more about PA Navigate

Leaders from Penn Medicine and Geisinger spoke at the 2026 Connect Summit about building Pennsylvania’s connected social care ecosystem. Penn Medicine focused on the procurement, implementation, and outcomes of the PA Navigate public-private partnership, and Geisinger shared how they use Findhelp technology to streamline clinical referrals, ensuring seamless alignment with the state’s ecosystem for improved patient outcomes.

Good day, everyone. Good afternoon. Good morning to some. We wanna welcome you to Paired Perspectives, building Pennsylvania’s connected Social Care Ecosystem. Find help, and our amazing speakers wanna welcome you today. And as a first activity, as you’re joining and just kind of coming on here, we’re gonna ask that you use the chat on the right hand side and that chat functionality to tell us what type of work you do and where you’re tuning in from, and that will help us to kind of fine tune our presentation today. So if you wouldn’t mind utilizing that, we would love for you to do that right now. So I just wanna give you a couple seconds to share some of the folks that are coming in and where you’re coming from. Ah, United Way. Welcome. Welcome. Thanks so much for being here today. We’re really looking forward to a robust conversation. Massachusetts, California, Idaho. This is fantastic. So glad that you could join us today. Georgia, South Carolina, Texas. Wonderful. Wonderful. Wonderful. Well, as you’re continuing to fill in that information and telling us a little bit more about what you do, we are gonna start to I’m gonna start to transition us so that we can begin these presentations. And so I just wanna make sure that you understand that we are absolutely about to take quite the ride. An ecosystem is a geographic area where living organisms interact with each other and their nonliving environment to function as a balanced unit. And our ecosystem today is going to be focused on social determinants of health or social care, so our speakers absolutely have some explaining to do. And speaking of explaining to do, I just wanna take a moment and explain to you who I am. My name is Tanoa Fagan, and I work for FindHelp as Pennsylvania state director. I joined FindHelp in twenty twenty three after approximately seventeen years of work with the Pennsylvania Department of Human Services. And so anyone that actually talks to me for any extended period of time will absolutely know and understand that my claim to fame is just the opportunity to help those that are in need. And so in my transition from Pennsylvania’s DHS to find help, I absolutely have the opportunity to do that and even in a broader scale at this point. And so I’m super excited to be here today and honored to act as the moderator. So before I introduce this first speaker, I just wanted to review a few housekeeping items for you all. First, this session is actually going to be recorded. Each of you will be able to access today’s recording this Friday, May the fifteenth. And in addition to that, if you have any questions, you’re already utilizing the chat, But if you would bump over to the q and a tab that is to the right as well, you’re welcome to put those questions in that q and a chat. And so what we plan to do, time permitting, of course, is we’ll do some of those questions live today. If we’re able to, we’ll also answer some of those online. So we really encourage you to do that and do that throughout. Our plan today is to let both of our speakers present, and then towards the end, we will just have a q and a session. Alright. So without further ado, we’re going to begin with our first perspective entitled aligning statewide infrastructure for social care coordination. This morning slash afternoon, depending on where you’re coming from, I’m going to introduce Keith Cromwell. He’s a corporate director for Penn Medicine, and in his spare time, he also oversees the health information exchange Central PA Connect. Of late, he’s been making his rounds across the country, sharing the PA Navigate platform and its success. So before I steal any more of Keith’s thunder, I’m going to welcome Keith to the stage today. Everyone, please welcome Keith Cromwell of Penn Medicine and the Central PA Connect HI. Well, hello, everyone. It’s great to be here today with you talking a little bit about PA Navigate and the journey that we’ve done in Pennsylvania. So as we kinda look at things, today, I’m gonna try and cover a little bit of the history and background, a little bit about timeline, talk about our implementation journey, and then really wrap up with what we’re seeing happen in the Commonwealth and what we’re seeing from an adoption and usage perspective. Before we actually hop in, though, I thought I’d just share a little story. So I’ve been with Penn Medicine for about twenty nine years now in a variety of different roles. One of the roles that I was in was actually going out and and talking in the community with different health care organizations, and just being a liaison to them. And one day, I happened to be, visiting one of our local missions that provides health care services. They’re a little early and got to sit in the waiting room waiting for the manager to to be ready, and I had a gentleman sit down next to me. I’m gonna call him Alex for today. And he really started telling me about his story. And it was a story that that had housing and food insecurities all woven through it. And as he was struggling with those things, he also die got diagnosed with a couple of chronic health conditions. And he was really struggling to just to know where to go get help at. Where where could where could he find that help? And, eventually, he he happened to be walking along, and and he happened to stumble upon a community based organization hub in the local area. And he was able to walk in, connect with them, kinda share his story a bit. And they said, yeah. We can help you. Here’s a packet of information. We need you to fill this out. That’ll help us determine whether you’re eligible and what services we can provide you. And he took that packet and went home, and, you know, it became quickly apparent he was illiterate. He wasn’t able to read the packet. He wasn’t able to actually figure out what they were asking for. So, eventually, he ended up abandoning it. So we fast forward a little bit, and he lands in the streets. He’s homeless now. And one evening, he’s in a park, sleeping on a park bench. One of the neighbors, Solid, calls the police. The police show up. Thankfully, the police listen to his story, and understand there’s a local mission in town that could really help him. And that’s actually where I met him at was at that mission. So they provide housing and and food. They also provide, you know, dental and medical services there. And then at that point, the manager came out, got me. I kinda went on with my day. Never got to see Alex again, but it planted the seed of we’ve gotta do better. There’s gotta be a better way to get folks help. So fast forward a bit, and PA Navigate and and all of the social care network in Pennsylvania started. So a little history lesson to start things off. We initially started out with a program that we called RISE PA, and it was initiated by the Department of Human Services. They went out to to procure a closed loop resource and referral tool. They went through the procurement phase. They actually announced a vendor, selected them. And as they were doing contract negotiations, they recognized that they had actually done this under an emergency procurement. And within the Commonwealth, that means it’s only valid for two years. And they knew that it was gonna be a rec procurement needed to start really before they even started the implementation, because a general procurement in the Commonwealth is about a three year process. So they decided to sunset that. They they actually clawed back that and canceled the procurement. And about a year later, they came to the HIEs, the health information exchanges in the Commonwealth, and asked us if we’d be willing to help do this project for them to procure the solution, manage the implementation, and ultimately administer the program. So four of us raised our hands and said yes. And in September of twenty two, we were awarded just over fifteen million dollars collectively, to stand up this program. And over time, we’ve actually increased that funding a bit. So we’re a little bit over twenty million at this point, in totality that has been allocated to the Social Care Network in Pennsylvania. So this is a a timeline, a general timeline. I don’t expect you to read it. I know it’s really busy. Put it in here just more as a reference for you. But but from a timing perspective, in twenty one, they initially came to us. In twenty two, they made awards, and we officially branded the program as PA Navigate. We went through our procurement journey. And in twenty three, we determined FindHelp was the best partner for us, so we engaged in a contract with FindHelp, in late twenty three. In early twenty four, we launched the program to the public and the citizens of Pennsylvania. And then the last year and and continuing into this year, we’ve really been focused on developing the network, getting folks integrated. We had some grant opportunities that I’ll talk about in a bit to help incentivize folks to get connected to the platform. And then as we kinda look at the next two years, that’s the final two years of our initial agreement, we’re really looking at where can we support other initiatives, things like eleven and fifteen waivers, rural health transformation, plans, things like that with an eye on sustainability. How are we gonna sustain this long term? And and as we kinda look at the network, this really is a complete network of partners. It’s not one of us that’s making this successful in Pennsylvania. It’s all of us collectively. So in the center, you can see, obviously, the Department of Human Services plays a huge role, the four HIEs with our our p three n network. And our role really, you know, between us is making sure we’ve got funding, kinda orchestrating the program, and then leaning on DHS to help with some policy alignments. And you can see around us, we’ve got managed care organizations and payers and health care providers. And and one of the groups that I would argue probably is most important on here is our community based organizations Because the rest of the ecosystem can do a ton of assessments. They can do a ton of referrals. And if there’s not a community based organization on the other side to provide those services, we failed. So the way that we’ve approached this is, obviously, we’ve got an agreement with Find Help. They have worked with the Community Action Association of Pennsylvania to help, be that community engagement partner for us. And we’ve got this big ecosystem, of partners that really have come together to make it successful. So let’s take a look at how we’ve kind of approached the implementation and what we’ve done to to facilitate the statewide network. So first off, we started with a strong governance structure. We have a steering committee that each HIE has one vote in. And at this point in time, DHS procurement was completed. DHS could come back into the picture with us. So they are on the steering committee as well, but they have a tiebreaker vote. I’m happy to say we haven’t had to use that yet. The HIEs have reached consensus on our own, but we do have them available, and their expertise is is in there guiding the process as well. And then we’ve formed some work groups to get into, like, some specific areas. So we’ve got a technical operations, community engagement, communications, and our poll our privacy and consent work group. And some of these work groups come and go as needed. So, we found that the technical and operations work groups really were focused on some of the same things. They wanted to know what’s going on with integrations and how are we moving the needle forward. So we ended up combining those two. So currently, we’ve got a technical and operations work group. And our privacy and consent work group did a lot of work in the beginning to lay out the foundation for how we were gonna do consents, how we were gonna administer it within the platform. Now, they’ve kinda taken a back seat because we figured that out at this point. But they’re still available in the event that we need to bring them back into the fold if we have a concern come up. So let’s take a look at that consent, mindset that we had and and the model that we used. So we have a dual consent process. We have a single consent per referral, and that generally is a verbal consent. Essentially, cons having the patient consent that it’s okay to share their information from a covered entity to a community based organization. Our second level of consent is what we call the coalition or data sharing consent. And this, we really looked at what was in the regulation in Pennsylvania. And act seventy six of six of twenty sixteen actually laid out the foundation for what we have as HIEs today in the Commonwealth. And when we looked at that regulation, we felt like social care really, folded into that very nicely. So we decided to use that same model. So we’re using the same opt out model, both on the clinical side as well as the social care side. And when we’re talking about data sharing, we really have it in two avenues. One is within the PA Navigate platform itself. So within the user face to find help, organizations can see referrals and assessments that were done by organ other organizations that are participating in the program as well. And, really, what we found there is that it really helps to streamline referrals to our community based organizations. They’re not getting overwhelmed with referrals because the organization that’s making that referral can see that last week, that patient was referred to a food pantry, and they don’t need to replicate and duplicate that referral. The second way that we’re sharing data is across our health information exchange infrastructure, and we do that by incorporating the social care right into the clinical care, of our document exchange. So if we kinda take that into a visual approach, we’ve got PA Navigate sitting on the Find Help platform as kind of the central repository of social care data. We’ve got our health care providers. We’ve got citizens that are going to the website. Obviously, our community based organizations that are receiving referrals and then ultimately updating, those statuses for us. We take that data, we push it down into the HIE repositories. And then the HIE share that across what’s known as the p three m or the Pennsylvania patient and provider network. And that’s our HIE infrastructure, and network that we use within the Commonwealth Exchange data. So we’ve got this ecosystem that’s just flowing, and we’ve made the social care data just shareable, as we do health care data. So as we talk about sharing, we always have to keep a lens on sensitive information. So there’s a few, areas that we actually block from sharing. One is our super protected data or what we call super protected data in Pennsylvania. And, essentially, that’s where Pennsylvania law is a little bit more stricter, than federal law, specifically around HIV, mental health, and SUD services. In addition to that, we heard from our members that it was really important to to isolate and and provide some protection around some other services, things like domestic violence and sexual health assault. So those things we also exclude from our data sharing network to keep our patients secure and to keep that level of trust high. I talked about community engagement a bit around CAP. Just to dive into that a bit more, the Community Action Association of Pennsylvania really plays that boots on the ground community engagement work effort for us. We were able to staff them with some community engagement managers that really blanket the Commonwealth. Regionally, they’ve got, different counties, and and their goal and objective is really to just engage with the communities, make sure that the CBOs have the training that they need, understanding how the platform works. And then they also help us with administering our CBO incentive program and help to identify partners that make sense for that program. We also have a trusted network that we work on developing, and we develop that with our CBO partners, that are recommended by our members and really are focused on those organizations and programs that are providing that top impact. They’re responsive. We’re seeing good results come out of those organizations, and we wanna promote them. We wanna make sure that folks are getting services. I did mention about some incentive programs and some grants. So I wanted to dive into those just a bit to share, what we did. So initially, during the first two years of the program, we offered system integration grants, and they were thirty thousand dollar onetime grants, to encourage folks to integrate their EHR platforms or their system of record into PA Navigate. And that could be through a variety of mechanisms, single sign on approach, a launch approach, deep integration into their system. The only thing that we really required was they had to be part of our coalition. They had to be willing to share data with us. And I’m happy to report that we had forty two organizations that were able to take advantage of that thirty thousand dollar grant, during the first year and a half or so of our program, which really helped to launch, the usage in of the program. The second piece that we’ve done is we’ve created a community based organization incentive. We originally started out with a million dollars. Dhs was actually able to see the benefits that we were starting to see from it, and based on that, infused an additional two million dollars. So we’ve got three million dollars across four years that we’re paying out to community based organizations, really to help facilitate their participation in the program. So you can see for small organizations, that that equates to about fifteen thousand dollars, and for large organizations, that’s twenty five thousand dollars. They’re unrestricted funds, so the CBOs are really finding that beneficial, especially in budget impasses and things like that. The things that we ask CBOs to do in order to achieve that is to claim their program, listing out there in the the platform, to accept electronic referrals for their programs, and then we ask them to meet some performance measures, just acknowledging that they received referrals and then letting us know what happened. And we’ve we’ve seen a really good, uptick in folks willing to do that for us. And just to point out, our trusted network partners, they include all of those incentive providers that I just talked about or programs, and they also include those nominated programs by our health care providers. This is just a quick screenshot of PA Navigate, and you can see we tag every one of our trusted network partners with that PA Navigate trusted network tag. And we also elevate them in searches so they appear at the top because we wanna funnel people to organizations that we know are making a difference and can really have that impact. And then from an implementation journey, this has to be the most exciting day that we had, and that was January twenty third of twenty four, which was our launch day. We had a large press conference joined by, the DHS secretary, doctor Valor Kush. We had our local county commissioners there. There was a we actually hosted it at a community based organization, and they got to to share some input into that as well. I was there to represent the HIEs and PA Navigate, and Erin Gray from Find Help was there to just help understand how’s how’s Find Help playing a role in moving the needle. I think what’s really exciting about this day is we immediately we got picked up by all the press, so social media, print media, television, radio, And we immediately started to see people use the platform. And we saw this big bolus of people, and the good news is that we haven’t seen it decline. So it tells us that what we’re working on and what we’re doing really is a need in the community. It’s what people needed. It’s what they were searching for. And it was really an exciting experience to see that happen. And even more exciting as we kinda take a look at what’s happening and what does adoption look like within the platform Because I think it’s really exciting. So first, I’ll start off with just what we’re seeing from a program perspective. So as I mentioned, the Community Action Association of Pennsylvania, is our community engagement partner. They work tirelessly to bring on additional programs and get them onboarded. Yeah. And you can see over the course of time this is a two year time frame. But over the course of time, month over month, we’re adding additional programs to the platform, increasing the directory, increasing the services that are available. I think what’s also important is as they’re adding programs, they’re not just adding a listing. They’re really engaging with those programs. So they’re programs that start to accept referrals. They’re programs that have had training in the platform. So it’s not just a increase the directory. It’s an increase the directory with quality CBOs. As we kinda look at it’s great to have a big listing, but are people actually using the platform? So as we kinda look at searches here, you can see in Pennsylvania, searches are very seasonal. And that makes sense. Pennsylvania’s got a very seasonal climate. We get warm in the summer. We get cold in the winter. We get less referrals, rest less searches in those summer months when it’s warmer, and we see a big spike happen when it gets cold. I think the important thing to look at here as we look at trends is what does it look like year over year? And we can see dramatic increases. If you look at the first, quarter of twenty four versus the first quarter of twenty five, you can see a huge dramatic change, with that same seasonality. Based on the trend line, though, you can see we’re going up, and that’s what’s important to us. People are continuing to use it, continuing to grow the platform. It’s one thing, though, to see people search. It’s another thing to actually see referrals traverse the network. So as we kinda look at referral statistics, those are more on a linear scale. They’re they’re they’re going up. So over the course of this time frame, about twenty one months here that’s represented, we saw a forty two percent increase in the number of referrals that are traversing the network, which is really exciting. So if you look at the current numbers actually from this last quarter that were just released, we’re well over sixty thousand referrals a quarter now that are traversing the network, which is really exciting, again, showing us that people are actually using the platform. And then we come to what I I just love this slide. I call this the money slide. This is why we do it. This is this is showing us that we’re actually getting adoption and usage within the platform. So, we initially decided to forego tracking our closed loop and acknowledgment rates and performance rates for a couple of months. We knew the Community Action Association needs some time to engage with folks, so we delayed that about six months from launch. And we started off with our first quarter, in twenty four starting in September. And our rates were pretty abysmal, to be honest. We had acknowledgment rates around twenty percent. Closed loop rates were riding around sixteen percent. This is where we started to infuse the CBO incentive dollars. We started to really work with, those CBOs to encourage them. And as a result, over the course of fifteen months that are here, we saw dramatic increases. So by the time we hit this last quarter in in twenty five, our acknowledgment rate was around eighty six percent. Our closed loop rate is at sixty eight percent. If you look at just closed loop, that’s a two hundred and seventy eight percent increase in fifteen months. And I always say, if someone can show me where to invest my money and make a return of two hundred and seventy eight percent in fifteen months, tell me where it’s at because I’m gonna invest. And, essentially, that’s what we’ve done. So we’ve invested in our community based organizations through the incentive program. We’ve worked with them, invested in time and training and efforts, from the Community Action Association, and we’re seeing the dividends. Right? We’re seeing those referral, closed loop rates increase. We’re not done yet. Right? Sixty eight percent’s really good. That’s close to national average, but that’s not good enough for us. So we’re pouring more dollars into the program, and continuing to push the needle, to make a difference in Pennsylvania. And as we kinda look at referral patterns, I always like this heat map because I think it starts to show us, where we’re seeing activity, where it’s most, prevalent. Not surprising in our regions where we’ve got a lot of urban folks, so in Philadelphia and in Pittsburgh, see a little bit up in the Scranton area as we get a little bit closer to New York City, and then in our capital around the Harrisburg area. But I think what it also shows us is that we do have some areas where we don’t see a lot of referral activity. We don’t have a lot of of services available. In that northern tier, you can see there’s some white space up there, a little bit along, our Maryland border, our southern tier as well between the Harrisburg and Pittsburgh areas. And I think what it’s starting to show us is where our white space is at. Where do we where do we need to to focus on? Department of Human Services is also looking at this data because they’re trying to figure out, especially with rural health transformation, how do they bridge some of these gaps? And this kind of data is really helpful for them to to figure out where do we push money to and and where do we enhance these community organizations. And then on the right side, just to give you a sense for what we’re seeing, again, not inconsistent with we’re seeing across the country. Housing and food, number one and number two, probably not surprising to anyone that’s on this phone, or or listening today. It’s what we expect to see. And then the last thing that I wanna share with you, is really where we’re starting to be able to demonstrate some impact of the work that p Navigate’s doing. And and this is really cool because we’ve got health care data because we’re the HIE community. And now we’ve got social care data that we’ve been able to layer on top of that and really start to look at what are the outcomes. So we have two early case studies that have come out of one of the HIEs. Both of these are courtesy of HSX, one of our HIE partners as part of the PA Navigate Coalition. And they looked at at folks that were referred to these organizations and looked at them one year pre and post enrollment in that program to really see what’s happening, what’s going on. And for the first organization, MANA, it’s a very large community based organization in the Philadelphia area. And with enrollment, what they saw was a twenty percent decrease in inpatient admissions post enrollment. They saw an eighteen percent reduction in emergency room visits, and then they actually started to see some chronic conditions be impacted. So a reduction in a one c’s, a reduction in BMI statistics. And as they looked at Pathways, another large organization in their community, they saw a thirty two percent reduction in emergency visits. Saw a slight increase in inpatient stays, but they saw a length of stay decrease. And I think what this is showing us is because we have the advantage of being able to layer all that data on top of each other, that we we all know or we’ve all heard the statistic. Right? Twenty percent of health care is about health care, and the other eighty percent is all about these social factors. And I think this data starts to show us that, that we really are starting to have an impact on that twenty percent by dealing with the eighty percent of their social care needs. So I think it’s really exciting. I’m excited to continue to see these develop, continue to see more and more case studies, continue to see more, benefits that we can demonstrate this way. With that, though, I’m gonna end my presentation, and I’m gonna turn it back over to Noah to introduce our next speaker, and share a little bit about how Geisinger and PNavigator are working together. Keith, thank you so much for your presentation. I hope that everyone is beginning to see that Pennsylvania really is leading the way as it relates to social care. The state of Pennsylvania actually has determined that in order to be successful in treating Pennsylvanians, we need to treat individuals holistically. And I hope you heard Keith call that out very plainly. PA Navigate is actually being utilized to make sure that all of the organizations that are involved in a person’s care have a uniform way that they can actually document how they serve a person, and that’s just fantastic. I mean, the system is even set up so that a health care organization that refers a person can even interact with those community based organizations that are providing those additional services. Keith also called out that relationships matter as it relates to the success of this platform. Our trusted network is actually filled with community based organizations that have agreed to actually receive a referral to reach out to an individual and then use PA Navigate to share how that individual was served. And those connections are what make the difference in the success and the failure of this platform. So we’re super excited about that. And because relationships matter, PA Navigate has an actual strong relationship with Geisinger. With that in mind, we’ve asked Geisinger to come to handle the second half of this presentation or the second half of our perspective. It’s entitled, Operationalize for Impact, Geisinger’s Community Health Strategy and Social Needs Resource Hub. Maria Welch is Geisinger’s director of community health and social needs. She does amazing work with Geising Geisinger’s specialized platform, Neighborly. Maria also is one that pulls double duty as she is the chair of PA Navigate’s community engagement work group. There, she works with Keith and I and the rest of the PA Navigate consortium to ensure that all of these connections run smoothly, particularly as it relates to with CBOs. Her years of expertise in this arena have proven to be a powerful asset in the building of this ecosystem. So everyone, please join me in welcoming Maria Welch of Geisinger’s Health System to the stage. Maria, feel free to take it from here. Wonderful. Thank you so much, Tanoa, and I’m excited to be here today to talk to you about more about our journey, and it truly has been a journey. I hope you leave here inspired through your own work, but also recognize that one thing leads to another. And, your evolution and your journey is the right one for your organization, but, hopefully, we can learn and inspire, those of you who are with us today. So on our journey and and our time together, we’ll talk a little bit about how we developed our strategy, how we use a six pillar system to drive the work forward, how we’ve integrated, three main parts of our social needs strategy, screening interventions, and our, really important connection to our CBO partners. How we’ve taken all that together, we’ve looked at data and have this evolution for an organization wide response around a social needs resource hub, and we’ll show you a little bit of some early data with that group showing us. So to give you just a tiny sense about Geisinger, we are an integrated health delivery system. So that means we are a health plan and a clinical enterprise. We are in Pennsylvania. We have a a footprint in Northeastern and Central Pennsylvania, but we are a statewide plan for Medicaid and CHIP across the entire state. We have ten hospitals. We have a school of medicine. We have a school of nursing, and we have over five hundred and fifty thousand individuals within our health plan. So lots of people getting care locally. We take a lot of pride in that. And I think you’ll see that that’s a a really important backbone of our community health work, who we are, and how we support our communities. Just to give you a sense again where we are in in those teal colors on the map show that we have the highest concentration of both our members and patients, but certainly have people statewide. So how did we get into this about, you know, eighty percent of the care isn’t clinical. It’s other factors that contribute to one’s overall health. And we recognize that, probably about ten years ago. We really started this journey having a focused approach on community health and social needs, and that has evolved over time. We’ll talk a little bit more about that in a few short slides, but really this is a pillar of our strategy. Our community health and social needs strategy really has six core areas that we have evolved and developed. And you can see that there there’s some really important common themes in here, you know, access to food and nutrition, social needs coordination, workforce development, removing barriers to care, chronic disease impact, and behavioral health. These six areas really help us to align the work. They support are supported strongly by data and insights and help us to make operational and strategic decisions. Now if we take that work and have one more click down under that social needs coordination, we have another layer of our strategy that really guides our work in the social needs space. And that’s kinda has three pillars. One of them is how we screen for information, but, really, it’s about the conversations we have with people to help identify those needs. Then how do we have interventions? How do we use tools like Naverley or pNavigate to find the right resources in the communities of people we’re serving and make sure they get those referrals for those really important needs? Then how do we measure outcomes? Because we can’t look at the work ahead if we don’t know where we’re going and where we’re at currently with data. So just to give you a sense of where Geisinger sits in this PA Navigate infrastructure, Geisinger is a member organization under Keyhigh. Keihai is one of the four HIOs that is part of the PA Navigate work and connected to the overall infrastructure that Keith talked about a little bit ago. So at Geisinger, we do have our own platform, which we’ll talk about here in just a moment, but we’ve made a talk. I liked, what Keith said about the connectivity, not only with the data and the infrastructure, but how we interact with people who live in in Pennsylvania. That is so important, and this ecosystem between our platform, Neighborly, and and p navigate has allowed us to have that insight and that connectivity, to, know how people are getting help and where they need to get help. And, again, Neighborly is Geisinger’s branded version of the find help platform. We just passed our six year anniversary, so, we, have been a customer for quite some time and have been really excited to have this be part of the PA Navigate infrastructure and have the ability ability to talk through coalition sharing. And as Keith mentioned, those we serve in our communities, might not receive care just at one place. They might receive care at multiple locations. And through that connectivity, so no matter, if we’re referring through a Neighborly or a p navigate, as long as that coalition sharing is in place, we can see how that person’s getting help. This avoids duplication, provides the best member or patient experience at the end of the day, gets people connected to the right resources faster. So we think a little bit about our journey, and where we’ve been. This just kinda gives you a snapshot of of where we’ve been. You know, most formally, our work started in two thousand and sixteen, and we had launched some programs like our fresh food pharmacy and our transportation initiatives. And that really gave us the catalyst to develop formalized strategies. So within there, we’ve launched steering committees and governance committees, that helped to navigate this work for Geisinger. We helped to operationalize the work and develop strategies. And then also, throughout their journey, we implemented Neighborly. So Neighborly is our resource and referral tool, like we mentioned, and that rolled out in twenty twenty with a quick follow the year after when we integrated it into our EMR. Throughout that journey, we’ve implemented various social needs screenings to help guide clinical and health plan conversations. We have an adult screening and a household screening, but, really, that’s the place where we start. The screenings help us to introduce the concept, understand where our members or patients are at, and guide those conversations, to really peel back. What are those needs? How do we foster trust in a place where private conversations are already occurring and making sure that we can, ask, what where do you need and how do we help you and to reduce those barriers. So, overall, as we rolled out our screening in many different locations, both in our ambulatory and our family practice centers, pediatric, maternity centers, as well as our inpatient and ED. Really, what this journey has taught us is we have a lot of screenings. We just reached our million one million screening mark that has allowed us to have lots of information, but it’s the value of those conversations that has really driven this work and where we prioritize where we’re going next. And that’s really helped us to launch our social needs research hub, which we’ll talk here about in a little bit about how we have a coordinated approach to have those conversations. And throughout there, our strategies have continued to grow. So I can leave you with one thing. As you as you listen to what we share, it truly is a journey. And as long as your journey is evolving from one thing to the next, you’re on the right track. So to talk a little bit more about our pillars, as you said, Neighborly is our resource and referral tool. We do have it integrated into our EMR. We do have a dedicated staff site as well as an app, with our goal in all of those locations to really help people connect in the right way in based on their preference to getting those resources. We have worked really hard in partnership with Findhelp to roll out our our Neighborly platform to different workflows, and this has really helped us to, think about where we can make it easy, easy for our staff to access, easy for it to be part of workflows, but most importantly, that go to and centralized tool for addressing social needs because then that creates the infrastructure for our entire, Geisinger family as well as allows it to grow with us with our community health strategy. So along our journey, and when we roll this out, we’ve really worked to customize the platform and our resources for our populations at Geisinger. So internally, we’ve built this infrastructure that complements not only our messaging around how the platform is used, but how the, information is rolled out to our staff. So we do offer live trainings to our clinical and, health plan teams. We do have self guided materials on our site that people can go to at any time. Doesn’t love a good two minute video to answer your question on the thing that you’re not sure of? And we can’t forget about our patients and our members. We have marketing materials to help people self navigate because we’ve learned very quickly that people might want to self navigate through the platform. So we have them available in ten different languages. We heard about data and how important data is. So we integrated our our neighborly data and our social needs data quickly into dashboards. So not only can we use them across the organization for strategy development, but also operational needs. So teams can self navigate. They can monitor how that is being done, and, those dashboards have grown with us. Has been an evolution, of how we look at the data and how we we stay connected and analyze it. We also do make sure we tag programs in our Neighborly platform. As Keith Keith mentioned with trusted networks, we also utilize that feature. So those, CBO partnerships come to the top of those search to make it easier. We do have our connection to PA Navigate for coalition sharing, and we do have and have leveraged technology, throughout this process as well by developing a neighborly bot to make the platforms talk, and also making sure that our CBO partners are at the core of what we do. We really couldn’t do this work without them. And having Neighborly be that centralized tool not only for our CBO partners, the network within FindHelp, but also all of our Geisinger led programs are centralized in one platform. It allows Neighborly to be the go to tool for all things social needs. So we train our teams for this, and it really has evolved and grown with us, which is exactly our goal. We want the tool to be helpful to and also to be under a consistent, phase of evolution because if it works for us and it grows with us, it’s a more powerful tool for our members and patients. So we’ve seen with, within our six year journey, we have over six hundred thousand searches on the platform and over eighty seven thousand users. So we have continued to grow over the years, and we’re excited to see where this takes us next. So I wanna walk you through a little bit about our journey. I talked a little bit about our infrastructure, but most importantly, it’s about where we’ve been and where we’re going and how we’ve been able to align these pieces for our strategy development. So core of what we do is really about aggregating data. Data from resources like Neighborly, our community health needs assessment, our social needs screening, just to name a few, has really become you know, how do we look at this? How do we look at this information? How does it grow with us? But most importantly, how does it help to identify, patterns and trends that can guide us to the next phase of our work? Through that aggregation of data, we’ve really identified there’s five core areas for Geisinger that we have focused and have additional strategic priorities and strategies. And that is food those five are food is health, transportation, housing, workforce, and maternal resources. Certainly, needs, might evolve outside of those five areas, but those are the five that we have identified as most common, have an additional strategic partnerships in those places to create a coordinated infrastructure. And, again, making sure that we have, team members who are dedicated to building out those strategies, developing partnerships with our community organizations, and making those connections through Neighborly becomes that centralized tool for those resources and coordination. And, again, the complement to that is PA Navigate. So as we’re building out these relationships and these partnerships, PA Navigate, becomes an extension of that network, not only from a coordination of how we share data, but also the networks that are being built out for that work as well. And then finally, making sure, in all of these places that we are complementing the work with having specialized resources like our social needs resource hub, specialized conversations to make sure we’re helping people navigate through those those needs. So what does it look like? There’s a lot on this slide, but really some takeaways are we have taken our data through many of those different aggregation resources like our community health needs assessment, social needs screening, Neighborly, our hub data, as well as clinical and health plan data. And we’ve really been able to to focus and boil it down into some key themes with within each region. Pennsylvania is a really big state. If you’ve ever been here, knowing that each region is very different based on the infrastructure, geography, and the people in which they live there. And that means different needs might surface in those different communities, and we see that through our data. So we’re able to adjust and pivot and align strategies unique to those different zones in Pennsylvania so that we have the right infrastructure to meet the needs of those individuals who live there. So you can see on this map, there’s some similarities across each zone. As as Keith mentioned, housing and food are generally one and two. Sometimes they flip flop based on the time of year, but we see that across many of our zones. But in some of our zones, transportation is number three, and sometimes data surprises us. Sometimes we don’t anticipate the needs, and that’s the beauty about looking at data. Helps us to identify what we don’t see or what we don’t know and also look for patterns and trends to anticipate. So, this slide is just an example of our infrastructure. So I mentioned food as health is one of our core areas. Within Geisinger, we have dedicated teams who are building out these strategies, building relationships with our community partners, which are integral to this work. And, again, I wanna echo what what, Keith mentioned that they’re really the core and the background bone of this work and the partnerships that we have with these community organizations are really where, the collaboration happens. We’re thankful for the work they do every day and know that we couldn’t be sharing this information, without their partnership, and and this map doesn’t do justice. But, really, I think it it provides an example of where those partnerships are, how we build out strategies, how we have taken what we’ve learned over the years with, like, data guide where we go, and build out a strong community health strategy. Now this is just a snapshot for food, but it’s really rep meant to represent the infrastructure that we’ve created. This infrastructure is represented in Neighborly. It becomes tools and programs and referrals that our teams can refer into, not only for our social needs resource hub, but for teams across Geisinger, which means, our teams have ways to find resources for the people they’re helping quickly and easily, especially when we have infrastructures in place for our community partners, to receive those referrals. So you guys know a lot of times conversations start around food, and oftentimes needs arise out of there. So, we have similar strategies for all of our different areas that we talked about, but this just I wanted to leave you with with one of them and the depth of our work across the end state, to support our members and patients. So lastly, to kinda wrap up, our work has evolved and has brought us to our social needs resource hub, which we recognize at the organization that conversations are so important. And that eighty percent that we heard Keith talk about, we don’t want that to be barriers to receiving clinical care. We wanna help people where they are on their journey and make sure that, the needs that arise, we have a way to help them. So we had an opportunity to centralize our approach, to centralize our coordination of how we address social needs at Geisinger. This really could not have been done without the strategies in place, the partnerships we developed, the tools that we have in our EMR, and and tools like Neighborly that have really led us to this part of our evolution. But our social needs resource hub launched in August of twenty twenty five, so it’s still pretty new. But it’s really a centralized tool, a centralized group of individuals, who help to address social needs. And in that hub, we have community health workers and behavioral health care connectors that have amazing experience in this space that allow us to have really focused conversations with people, who have identified social needs and want help navigating through that journey. So we’ve integrated this into our EMR. We’ve we’ve used Neighborly as our resource and referral tool. And, really, at the end of the day, the goal is to have a place for people to have conversations, a way to have the best member and patient experience helping to address social needs, connectivity to tools like pNavigate, but also connectivity within our own organization. We recognize that people receive care in many different places clinically, And our goal in having this hub to not only be centralizing those conversations, but to have visibility and connectivity within our EMR that allows us to show individuals across our organization how social needs are being addressed, how the conversations are occurring, where resources have been referred to, and where that person has gotten help. All of that is visible and really important to the care we offer within those clinical conversations, but, also, it allows us to pull and aggregate data on the back end to really look at the impact of this work. So within the first couple of months of the hub being launched, we recognize that, our rollout and our complement to different areas of the organization is gonna look very different. But, really, what this shows is we are working, and part of our journey for rollout is to complement these different areas within the organization. Where areas might have a bigger need for social needs resource coordination, the hub takes on and fill the fills those roles so that our clinical teams can have more clinical conversations. Social needs can have, social needs conversations. Where infrastructure or resources already exist, we’re complementing these workflows to say, how can we work together to support you? How do we make sure we have the right conversations, the right resources, both short and long term for the individuals who are receiving care? We’ve integrated and used Epic Logic, to bring those resources into the hub with the consent of individuals, making sure that they’re opting into that help. We also identified that we need some ad hoc or communication pathways outside of those formal screenings, to help identify needs getting them into our resources and getting them into the hub. And we also quickly learned that we needed a non epic referral pathway, which we actually use Neighborly to refer to ourselves for teams like customer care or wellness teams who aren’t using and working in our EMR, but we still need to get them into that central intake of that central pathway into our hub. So we’ve really leveraged the tools that we have, the infrastructure we have to create this, you know, resources for people to get care. And then I’ll leave you with this last slide. This is some early data that we are seeing throughout the hub, and I think it it, it complements what Keith was saying about the infrastructure and seeing numbers increase. And this just becomes a snapshot of that information, a snapshot of what we’re doing at Geisinger with our social needs resource hub. But you can see in the first, six months of being live, we’ve had over two thousand referrals come into the hub. And we’re proud to say that through those focused conversations, the infrastructure we’ve built, we have an eighty four percent, gap closure rate of getting people connected, to resources through referral pathways within our network. We have a lot of success at getting people connected on that first connection, but we know that everyone’s in a different place in their journey. So within the hub, we do have dedicated reach outs, a dedicated time frame. So we do carry a caseload to make sure that individuals are helped because every journey is different. We also leverage tools like Find My Ride. That’s a transportation portal to get people connected. And, also, we’re finding that because of that opt in approach to the hub, a lot of people are engaging when we’re calling them, and they’re remaining engaged throughout that journey of getting help. So we have about a ninety three percent engagement rate in the hub and a very low, unable to contact or an opt out rate. And, again, we’re seeing different data through those resources and connections, but most importantly, we’re able to pivot and adjust, based on that data. So I’ve shared with you my journey, and, certainly, it’s a journey. We’re not done. And, where we’re going next is continued expansion of our hub, continued partnership with with our community based organizations. We have over a hundred and twenty five in our trusted network, and we’re excited to see that grow. And then certainly ongoing, integration with Find Help to pull membership data through APIs. So we’re equally excited for where we’ve been, but also excited for where we’re going. And I hope that this has given you a snapshot, not only what we’re doing at Geisinger, but how we’re integrating into a larger, statewide network with pNavigate and leveraging tools, like Neighborly in our day to day work. Thank you so much for the time today. Thank you so much, Maria, for your presentation. As you can see, Pennsylvania continues to make those connections in numerous ways, and they’re also interconnected through social care platforms like PA Navigate and, of course, Neighborly PA. And so, again, Maria, thank you so much for taking the time to share with us today. And at this time, we’re actually going to take some time to respond to some questions. And if you haven’t placed any questions in the q and a tab there, you’re welcome to continue to add them right now. We have a few more minutes to do that, so we’re gonna get started here. And let’s see. I think the first one we are going to go with, someone came right for the hip, is the question, how will these services be financially sustained? And so gonna offer that or extend that so that you all can share what our model is to try and sustain some of this work financially on an ongoing basis. Yeah. So I can I can start off just from the PA Navigate perspective and what we’re kinda looking at? So I think there’s there’s a variety of things. One thing is we wanna show value. Right? Because we feel like if we can show value, you know, those case studies are a good example. They’re early case studies, so they haven’t been published yet. I know that was a question that was in the chat as well, and we’ll try and get you some some prepublished case studies. But, essentially, if we can prove to the payer community that it’s beneficial, right, you’re seeing a reduction in cost, for not as much in return that that you need to pay to support the program. That’s one avenue that we’re kinda looking at is if we can show the benefit, we’ll ultimately be able to sustain the program with funding, from our membership base. I think we’re also looking, you know, at all the opportunities. So does it make sense to partner on eleven fifteen waiver concepts? Does it make sense to partner with Rural Health Transformation? And I think it does. I mean, I think we we have talked a lot with the DHS secretary around it, and she’s been very open to we wanna make this successful. We wanna make this sustainable. We wanna figure out ways to to make it happen. So I don’t think there’s a one size fits all answer to that question. I think it’s a combination of sorts, a combination of membership, supporting it because they’re finding value in it. They’re finding, you know, trends that are that are showing that it’s valuable, but at the same time looking at, you know, where do we have funding opportunities out there, for support. Wonderful. I would echo a lot of what Keith mentioned, and and I think it’s about, also being able to use the same recipe. So where p and navigate might be looking and and showing impact through their work, where do organizations have the same recipe with community engagement, resource coordination. And I think it allows not only the work that’s being done by one organization to be amplified and then, you know, impact aggregated over a larger scope. And I think data also becomes really powerful, not only when you think about sustainability, but thinking about long term support, like grant or foundation or philanthropy support. Data helps you to to move in that direction and to think about additional avenues once you’re beyond implementation. Thanks so much, Maria and Keith there. I’m gonna keep going because these questions keep rolling in here. So the next question that we have here is, do you find that there are any challenges with the capacity or bandwidth for CBOs to meet the demand of referrals slash people that need help? Not at all. No. Of course. Of course. Right? I think that’s that’s a challenge across the board. I think even with, you know, some of the the financial strains that CBS have had over the last year around budget impasses and changes to the benefits and and more demand, I it it is a struggle. Right? It’s it’s something that that we face every day. And, you know, I think it’s to to try and overcome that, I mean, the our communication partner, CAP, has done a great job trying to educate programs and CBOs on on how to to kinda get them through that. And and, honestly, the data doesn’t say, at least at this point, that when you magically become part of our trusted network that you start to get thousands of referrals. You know, you get referrals, and you’re a a good partner, and you’re able to respond to them, but we’re not seeing this huge influx like, most people think is going to happen when you kinda flip that switch. It’s still an engagement aspect. Right? You you’re still building those relationships. Some of what we’ve done, obviously, is the CBO incentives. Of course, twenty five thousand dollars isn’t gonna keep a CBO going for a year, maybe even a month in in some of the larger cases, but we’re looking for opportunities like that, and we’re sharing them with our membership base as well. I know another example that came out is there’s a a maternal health initiative in Pennsylvania that the HIEs have really been working with, and they came out with some grant opportunities for community based organizations. So we’re we’re out there promoting that and saying, hey. Here’s some other opportunities. So we’re helping them from a an opportunity perspective as well to help build their infrastructures. But it is certainly something that we struggle with that we need to work through and and partner with them on. Thanks so much, Keith. And, Maria, I’m gonna queue you up here for the next question here. Do you promote Neighborly primarily as a self referral and resource platform for families to explore on their own, or is it used more as a platform where families and community members come to you for support and referrals? It’s a great question, and, I think it’s both. So we started out in this journey, having Neighborly be community first, not only for our community partners, but for those who needing help. And we actually launched right before COVID shut us all down, so it became really important in that time frame. So we do heavily promote it as a self referral and resource platform because we quickly recognize lots of people wanna self navigate, or share it with a family member or friend. But equally important is our internal infrastructure. We have those coordinated conversations and really where our social needs resource hub has become an important part of that journey. We hope within, our our phased rollout within our social needs resource hub that we do have the ability for people to call in. Right now, we are internally supporting our workflows and having more of a call out infrastructure, but we think we’re gonna quickly get to that part, and our data is really showing us. So there’s a kind of a there there, and there’s a a definitely a positive aspect for that. And we’re actually finding a lot of our younger populations who opt into the hub just need that little bit of a start of where do I go to look, and they’re able to then self navigate through those needs. So we’re getting some really great data through those interactions that’s gonna help us to say where we go next. Thanks so much, Maria. We’re about at time, and so I am going to take this moment to thank you all for joining us today and want to encourage you to complete the survey that is about to pop up on your screen right now. And while that is that change is taking place here, we are going to say thank you so much to Maria and to Keith for taking the time to share with us today. We’re so excited that you were able to be here, and, you found today absolutely inspiring and helpful. And, again, please fill them with emojis to share your gratitude here. We are going to publish the survey for you and would ask that you take the moment to answer these two questions for us before you go. Alright. Alright. Hopefully, you’re able to see that at this point. Wanna take the time one more time to thank you for joining us today. Again, we hope that we’ve inspired you and encouraged you to be like Pennsylvania. In Pennsylvania, you’re not part of the PA Navigate platform. You’re also working with amazing organizations like Geisinger’s Neighborly program. And, again, our goal is to create an ecosystem that utilizes all of these services so that people in Pennsylvania can receive what they need and so that we have the data necessary to support any additional needs that the state would have on an ongoing basis. So, again, we encourage you to reach out to us if you have additional questions or things that you’d like to talk about. We’re here for those things. Thank you so much for joining us today. Have a wonderful day.

Community at the center: Elevating Pennsylvania CBO voices

Community-based organizations remain at the heart of Pennsylvania’s social care ecosystem. During a panel focused on CBO engagement, speakers discussed strategies for helping organizations adopt new technology, strengthen workflows, and participate more fully in statewide coordination efforts.

Panelists—representing Children’s Hospital of Philadelphia (CHOP), Siloam Wellness, St. Luke’s University Health System, and Community Progress Council (York County Community Action)—highlighted the importance of supporting organizations beyond implementation, providing training, workflow guidance, and ongoing partnership to help teams successfully manage referrals and engage with community members.

The discussion also highlighted PA Navigate’s CBO incentive program, which is helping organizations claim and maintain program information, respond to referrals, and build sustainable participation in the network.

More than funding alone, panelists emphasized the value of helping organizations develop the operational capacity needed to succeed.

Data emerged as another important theme. By analyzing searches, referral activity, and community trends, organizations can better understand emerging needs, identify service gaps, and make more informed decisions about where to invest resources.

The result is a stronger network that benefits residents, healthcare organizations, and community partners alike.

Beyond the Summit: Our work in Pennsylvania

While speakers represented different sectors, organizations, and perspectives, the conversations throughout the summit reflected remarkable alignment. Whether discussing Medicaid policy, healthcare integration, community engagement, reimbursement models, or referral outcomes, participants returned to the same core idea: creating a connected system requires collaboration.

Pennsylvania’s leaders are working to build infrastructure that reduces fragmentation, strengthens partnerships, and helps residents navigate services more easily. As organizations across the Commonwealth continue investing in shared technology, coordinated workflows, and community-driven partnerships, they are laying the groundwork for a future where healthcare and social care work together seamlessly.

The Pennsylvania Social Care Summit provided a rich day of insight and connection, but the real work continues — in homes, clinics, schools, and community hubs across the state.

Some numbers that show the scale and momentum

11,800 listed programs serving Pennsylvania
4.8 million users across the state
11.9 million searches for resources
100% of counties have claimed programs

As of June 2026, we partner with more than 71 customers throughout the state. They use the Findhelp platform to connect their patients, members, students, constituents, and clients to local resources. Our data and analytic tools can identify gaps in services and provide actionable insights to inform strategy and public policy.

*Searches in Pennsylvania on Findhelp platforms, Q1-2020 through Q1-2026*

Let’s keep the conversation going

The path forward will require continued innovation, investment, and collaboration, but the momentum was clear throughout the day. Pennsylvania is not just building a network of services. It is building a more connected, coordinated system of care designed to improve outcomes for communities across the state.

If you’re interested in how Findhelp can support your work — whether you’re a health system, community-based organization, payer, or state agency — we’d love to chat.

Chat with us

No Wrong Door is a podcast from Findhelp that explores how social care delivery is evolving to better support whole person care. Hosted by Findhelp VP of Marketing Amy Gordona, the series features conversations with social care experts, healthcare and government innovators, and Findhelp leaders who are shaping the future of access, coordination, and connected care.

Each episode offers an inside look at the systems, decisions, and ideas driving change—and what it takes to build a social safety net that works at scale.

Getting connected to behavioral health care should not feel like an obstacle course built from spreadsheets, dead phone numbers, and five-month waitlists. But for many individuals and families, that’s still the reality.

In episode 8 of No Wrong Door, Amy Gordona sits down with MiResource co-founder and CEO Mackenzie Drazan Cook to discuss why behavioral health referrals so often break down, how outdated provider data creates barriers to care, and what it takes to build behavioral health networks that actually work for patients, providers, and care teams alike.

Drawing from personal experience navigating mental health care with her sister, Mackenzie shares how grief, frustration, and curiosity ultimately led her to focus on improving the infrastructure behind behavioral health referrals and provider matching.

In this episode, we explore:

Why behavioral health access problems are often data problems disguised as provider shortages

How inaccurate or incomplete provider information delays care and contributes to patient drop-off

What coordinated, searchable behavioral health networks could mean for hospitals, care teams, and whole-person care delivery

Watch episode 8: “Closing the Behavioral Health Gap”

Key themes from the conversation

Behavioral health care is deeply personal, but the systems supporting it are often fragmented, manual, and difficult to navigate. Throughout the conversation, Amy and Mackenzie explore how better data, better coordination, and more thoughtful referral infrastructure can help close gaps between referral and care placement.

The hidden complexity behind behavioral health referrals

Behavioral health matching goes far beyond finding a nearby therapist. Patients often need providers who align with clinical severity, accessibility needs, insurance coverage, transportation realities, cultural preferences, language, and personal comfort levels.

Mackenzie explains that successful behavioral health care depends on solving for all of those factors simultaneously, not just availability.

The conversation highlights how difficult this process becomes for people already struggling with depression, anxiety, grief, or other mental health conditions. Even motivated patients and families can face overwhelming barriers trying to navigate fragmented provider networks.

“If any of those three buckets [clinical severity, care accessibility, and cultural context] are not solved for, you’re not going to have a good therapeutic outcome.”

Mackenzie Drazan Cook

Co-Founder and CEO of MiResource

Behavioral health access is usually a data problem

One of the episode’s clearest themes is that many breakdowns in behavioral health access stem from incomplete, outdated, or overly simplistic provider data. Amy shares her own experience helping her mother navigate mental health care after a family crisis, describing how difficult it was to identify providers who met specific needs around grief support, accessibility, and location.

Mackenzie argues that healthcare systems frequently treat behavioral health directories like standard medical directories, even though behavioral health care is far more individualized and fragmented.

“I fundamentally believe that at the root of this problem is a data maintenance problem.”

Mackenzie Drazan Cook

Co-Founder and CEO of MiResource

The discussion explores how missing details, such as provider specialties, accessibility accommodations, patient preferences, or real-time availability, can derail referrals and delay treatment.

The process often breaks after the referral is made

A recurring challenge in the episode is the gap between making a referral and successfully connecting someone to care.

Many care coordinators, social workers, and primary care providers rely on small referral pools, static spreadsheets, PDFs, or outdated lists of clinicians. Patients are often left calling provider after provider, only to discover long waitlists or providers who are not the right fit.

Amy notes that even families with insurance, internet access, and strong support systems can struggle to navigate the process. Without support, many patients disengage before they ever receive care.

“Actually finding and connecting with care is Mount Everest number two. Mount Everest number one that you have to climb is making that brave step of saying, ‘okay, I’m ready to get help and I want to get help’.”

Mackenzie Drazan Cook

Co-Founder and CEO of MiResource

Connected behavioral health networks for whole person care

The conversation also explores how the partnership between MiResource and Findhelp can help create more connected behavioral health referral systems.

By consolidating fragmented referral lists, verifying provider information directly with clinicians, and integrating behavioral health resources into broader social care workflows, organizations can reduce administrative burden while improving patient outcomes.

“It’s really about meeting patients where they are, not requiring them to speak the technical language of the health industry.”

Mackenzie Drazan Cook

COO at Co-Founder and CEO of MiResource

Amy describes a future where behavioral health referrals, transportation support, food access, and clinical care all exist within a connected longitudinal care record, giving providers a fuller picture of a person’s needs over time.

The episode closes on a hopeful note, emphasizing the dedication of behavioral health professionals, social workers, and care coordinators who continue pushing for better systems despite persistent barriers.

Learn more about MiResource

Earlier this year we hosted a behavioral health webinar with Mackenzie and other guests to explore how clinically-aligned behavioral health networks, real-time provider availability, and integrated social care connections can replace today’s fragmented directories.

Alright. Welcome in, everyone. We’re so excited to have you here today. It is eleven thirty three on the dot, so we’ll go ahead and get started. I know we had close to seven hundred RSVPs, and I see a couple hundred on the line today. I think the the attendance that we have today here just really speaks volumes to how important it is to access behavioral health in today’s day and age. So let’s go ahead and get started. My name is Delaney Baldman. I’ve been at Find Help for about four years now and have played many roles, but my most recent one is as a senior business solutions architect. And I’ve really been bringing the behavioral health specialty network to life at Findhelp. So very excited for today’s launch. Joining me today, we have several panelists that I’ll allow them to go ahead and introduce themselves real quick, And we’ll start off with Joffer. Thank you, Delaney. Welcome, everyone. I’m Joffer Trash. I serve as the chief operating officer at Find Help, and we’re humbled to have you all here with us today. I’ll pass it to Mackenzie. Super. Thank you, Jafar. Hi, everyone. My name is Mackenzie Draisen Cook, and I am the CEO and cofounder of MiResource. And I’ll go ahead and pass the torch to Lindsay. Thank you so much. I am Lindsay Oberleitner. I am the head of clinical strategy at Simple Practice and a clinical psychologist myself. So grateful to be here with all of you today, and I will pass it to Wes. Thanks, Lindsey. I’m Wes Nepper. I oversee SonderMind’s clinical programs. I’m a therapist by training and excited to be here. I think it goes back to Delaney now. Great. Thank you all, and we’re gonna be hearing a little bit more from our panelists later on. What to expect for today? We are really setting the stage for Find Help’s behavioral health specialty network. It’s our first official launch of this network. Joffer and I will be sharing the vision behind the behavioral health network at Findhelp, the why, and the problems that we are attempting to solve to solve. We’re also going to learn a little bit more from our partners who are actually powering the network. I’ll provide a quick demo as well about what this looks like in practice for the end users today. And then we’re gonna have a partner panel discussion and then live q and a. So throughout the session today, please feel free to use the q and a icon at the bottom of your screen to go ahead and log questions. So just a quick couple of housekeeping items. Yes. This recording, this webinar is going to be recorded, and we will share it out later this week at the end of the week. And, again, we have a little icon there about how you can actually go ahead and submit the q and a as well. Okay. So a lot of you have been customers with Findhelp for quite some long time. So you’re well familiar with our mission, which is to connect all people in need and the programs that serve them with dignity and ease. The vision that we have is really powering the American safety net by simplifying the process of connecting people to help. In the past, that has really meant social care and social services. But today we’re going to dive into how we are expanding that into behavioral health as well. Thanks, Delaney. And for those of you that have worked with Find Help over the years, you’ve known that we’ve always been powering social service referrals, primarily free and reduced cost direct service programs and supporting many of your own internal programs that you offer from your own unique organizations. And this goes beyond health care. This reaches into the, education space, into the government sector, and also into the employer space. We expanded that work to social care fulfillment, and that really is delivery of goods and services. For example, diapers and pest control and other services that help people get to their appointments such as transportation, and furthering that work with claims and reimbursements support, including with CMS waivers. We have recently expanded that work into government benefits, helping people with income based government benefit enrollment, most recently with Medicaid redetermination, and helping people submit and track their applications. Lastly, we’re really thrilled today to speak to our specialty networks work that Delaney has been leading the charge on, including with behavioral health. Great. So we’ve often heard about the behavioral health provider shortage, but we really only believe that that is just part of the story. Yes. Demand is rising. More than one in five adults experience mental illness annually, and youth needs are increasing at an even faster rate. But we believe that the deeper issue isn’t that providers don’t exist. It is that we are inefficient at connecting people to the providers who actually do. Eighty one percent of listed clinicians in federal studies are unreachable or out of network. So what does this really tell us? It’s not just a capacity problem. It’s a data and coordination problem as well. And now with CMS enforcing ninety day verification and significant fines for inaccurate provider data, this really isn’t just a user experience issue. It’s also now becoming a compliance and financial risk issue as well. So the problem we’re solving is better infrastructure to connect people to the right providers with accurate and usable information, which brings us to the important nuance when actually finding a match for a provider in the behavioral health space. Just because someone is credentialed doesn’t necessarily always mean that they’re a good match. Behavioral health is extremely relational, and a referral doesn’t just succeed because the license is correct. It succeeds because the provider treats the right populations. They use the right modalities. They accept the right coverage, and they align culturally and clinically with the patient’s needs. That’s the clinical mismatch problem. Most behavioral health providers are also solo practices practitioners today, and they’re not updating multiple systems daily. So directory data quickly becomes outdated. And finally, scale. Most public directories simply aren’t built to capture the nuance required for behavioral health matching. So sustainable access requires more than just a list of providers. So I’ve just talked through some of the challenges and inefficiencies within the behavioral health space. So why do we at Findhelp want to take on this challenge? And to us, honestly, the answer is very, very simple. Social care and behavioral health have a deep correlation, and mental health does not exist in a vacuum. If someone is struggling with clinical depression or battling addiction, often those needs need to be addressed first or alongside needs such as food insecurity or helping pay for utilities. This is where our behavioral health network comes in, and we are focused on really two main elements in this network that we are providing. One is our strategic partnerships, all the folks that are on the line with me today. We’re not trying to rebuild behavioral health networks from scratch. We’re partnering with behavioral health organizations that already maintain accurate and clinically nuanced provider networks today. The second element that we are focused on is actually providing that unified search. So the care teams, the discharge planners, the the caseworkers, the social workers that are oftentimes already searching for behavioral health and social care can do that in just one place. So our goal is to actually provide a unified search to actually provide that to care teams. Thanks, Delaney. And lastly, for this to be successful, we need to recognize that, one, part of our success has been a no wrong door approach to where people receive care. And secondly, many of the users that are navigating for behavioral health care to assist people coming in their door are using electronic health records and case management tools today. And we have to drive parity of an accurate search through much of the existing infrastructure that is across the United States today. And we do that. We do that by modernizing the workflows inside of the electronic health records and case management systems, by ensuring an accurate data driven compliance, by bringing the data about providers into those case management systems, and making sure that customers have control over the types of networks that they want to include for the right types of a population. So this really brings together much of what Delaney’s described and Find Help’s natural approach to integrating information into the systems our customers use. So our behavioral health network vision. It really is one search, all services, and this is something that we’ll be continuing to march toward with the years to come, helping organizations not only find the right social care support and fulfillment, but the right potential government benefits, post acute care, and now behavioral health, making it easier for a navigator to reduce the number of systems they’re using and have more efficient, more effective workflows inside of their daily, infrastructure to accomplish their goals with their population. So behavioral health care. Let’s jump in. First, we’re really excited to welcome three partners to the webinar today: Simple Practice, My Resource, and SonderMind. And we’ve selected these three because we believe they’re mission aligned and they carry the same integrity that we believe is necessary for continuing to march forward in simplifying and streamlining access to behavioral health practitioners with those principles that we’ve described. So to kick us off, let’s hear from each of our partners to start, and then we’ll dive into the future Find Help workflows that we’ll be supporting together. Simple practice. Thank you so much for that handoff. I’m so excited to be here and so excited about, partnering with Find Help. We at Simple Practice want to share a little bit of information about who we are and where we sit, in the behavioral health field. So we, sit as the core operating system for independent mental health providers. And we believe deeply in the ability of technology to serve as a connectivity layer to the nationwide, mental health clinician base. We know historically independent practice, as we’ve already heard a little bit today, can be fragmented and hard to reach at times. And additionally, as representing the many clinicians who use simple practice, many clinicians feel that desire to be able to connect more into broader systems, into health systems, into other social service agencies as well to build those connections and ensure the best care for their clients. So our mission is to empower independent mental health practices to thrive, and we do that by offering all to our customers, our behavioral health clinicians, all of the services to run their practice, meaning we are integral in their daily workflow. This is how they have client communication, deep information about who they serve, what practices they engage with, what insurance and payment options that they have. It allows them to communicate deeply within our website. In addition to maintaining documentation, it also allows them to deeply be involved in the scheduling flow to ensure that clients, patients do not fall off in that process. We build technology tools to make this easy, something that has been historically, as a clinician myself, having been there within systems, hard to ensure that continuous flow and connectivity to the system. And we’ve also worked hard to make billing something historically difficult for behavioral health to manage as simple as possible. In fact, so much so that we have seen an increasing amount of clinicians on platform who bill insurance with approximately half or more of payments on our system of the twelve billion that we see going through being through insurance. And, as we think about the next slide, this is at a very large scale. When we think about one thing already mentioned by Delaney earlier is how many solo providers there are in the community. So SimplePractice has over two hundred and fifty thousand, clinician users on our system, and that represents ten million patients served annually. When we think about that ten million number, that is approximately three percent of the US population, but even more meaningfully, probably about when we look at estimates of who seeks outpatient mental health care, ten, between fifteen and twenty percent of care that is provided. And every month, we are seeing a very active amount of clinicians and also that many, approximately forty percent, have appointment availability within the next five days. So as we already heard, sometimes the connection issue is finding the right person who offers the right services and actually being able to access them. And that’s something that we allow through some of our options like online scheduling. And finally, really important about the customers who use SimplePractice to run their behavioral health, mental health practices, they are throughout the United States. They are deeply embedded in the communities, and they provide a wide variety of treatment. And again, we see all of this as we see their care day in and day out, what they’re providing on our platform. So there is a range of specialties, both across license types from both prescriber through, all the primary behavioral health license types and across a variety of populations served. Forty two percent report treating individuals under the age of eighteen. Many individuals report serving, Spanish speaking primarily and across different diagnostic categories because we can help support and see the data and who they’re seeing and continue to find the right individuals and the right match. And one one other note, just as we think about the spread throughout communities, a large number of our clinicians using simple practice also reside in some of the states with the lowest mental health access, truly integral across the United States. And, I thank you for some time to share a little bit about Simple Practice and about the Simple Practice, the community of clinicians who use Simple Practice. But I will now pass this over to Mackenzie. Thank you, Lindsey, and thank you so much for having me, I’m gonna spend the next few minutes on a problem that every Find Help customer who is looking to connect care seekers to mental health care runs into. Behavioral health referrals are only as good as the provider data behind them. Most institutions probably already have a referral list in some form. Sometimes that might be a PDF. Sometimes it’s a shared Excel file. Sometimes it’s a Word document. And in many organizations, the most important information is actually not written down anywhere. It’s held in the heads of the case managers, of the social workers, of the care coordinators who have been doing this for years. Teams generally often intend to update those lists about quarterly or annually, but in reality, this rarely happens. Behavioral health is too fragmented and the information just changes too quickly. So the result then is predictable. A case manager starts a referral, calls the first provider, finds out that they’re not taking new patients, they call the second provider, they learn they don’t take post discharge patients, they call the third, and intake is only on Tuesdays and Thursdays. Meanwhile, the patient’s waiting and the staff time per referral is going to balloon. This is the exact problem that my resource was designed to solve. My resource is a behavioral health provider network data service. You tell us which providers you want in your preferred network, and we collect and maintain the data on those providers so your team can make fast and confident referrals. And this is important. My resource manages the data behind the scenes, but your team keeps using Find Help as the interface that they already know. The main reason most provider directory systems fail for behavioral health is that they were built for medical providers, and medical networks typically have admin support. Someone answers the phone, someone updates the directories, but behavioral health is very different. It’s dominated by solo practices and small groups, and then you have the other extreme, where you have complex programs like residential treatment programs, partial hospitalization programs, IOPs, and these provider types operate completely differently and require different engagement systems if you want to have accurate data on the full continuum of care. And that’s exactly what my resource was built for. We tailor our provider engagement based on provider type so that you get really core accurate data on everything within your preferred network. So what kind of data are we talking about? This isn’t just name, phone number, and address. Those fields are table stakes. The data that actually determines whether referral succeeds includes things like, does the provider have availability right now? Do they accept patients who have recently been discharged from the hospital? Do they hold appointments for post discharge patients? Do they accept high acuity needs like self harm risk, suicidal ideation, eating disorders, or psychosis? If it’s a program, what days do they do intakes, and is intake rolling or scheduled? Those are the details that really drive referral outcomes, and without them, staff are gonna spend time chasing dead ends. So here’s what the model looks like in practice. You give us the list in whatever form it’s in, it could be a spreadsheet, a PDF, a Word document, a folder of different documents, and then we take it from there. We directly engage the providers to create profiles, and on average, we collect over one hundred different data points per provider. Then we continuously verify and refresh that information so that the data stays current over time. My resource can also work with you to grow your referral network, so you can have your original list of providers and simple practice providers and SonderMind providers all in one place. And this is something we can really point to real outcomes. We consistently see institutions reduce referral times per patient from about sixty minutes down to ten minutes once they have accurate searchable provider data. We also see really strong provider engagement. Today, eighty percent of the My Resource provider network updates their availability every fifteen days. This means accurate availability on even your solo practices and providers, which are the hardest groups to engage that still use analog, haven’t switched to digital scheduling tools. For customers who need it, we have a hundred percent compliance with CMS ninety day provider attestation requirements, and we have really strong proof that this works even when providers are not digitally activated. With MyResource clients, we see about only ten percent of their network, their providers use digital scheduling tools. We would love it if everyone used simple practice, but unfortunately, sometimes the reality is that you may have providers that still prefer phone call outreach. So that’s exactly what we’re designed to do is to be able to make sure that you have connectivity to even the hardest to reach providers. My resource supports over eighty university counseling centers across the US, and we maintain data on a large national provider network. We also support the United States Olympic and Paralympic Committee Psychological Services Network, and we’ve worked with hospitals and health insurers. So if you’re a Find Help customer who wants behavioral health referrals to be faster and more reliable, the core idea is simple. You control who’s in your provider network, my resource maintains the accuracy of that network, and your team continues to make referrals inside FindHelp, but with data that they can trust, and that’s what we’re bringing to this partnership. Thank you so much. Alright. Thanks, everyone. So I’m Wes Knepper again. I’m here to talk a little bit about SonderMind. SonderMind is a nationwide behavioral health provider. We provide therapy and psychiatry services in all fifty states in DC, and it’s really a technology enabled platform. And so we’ve talked a lot about the, individual practitioners that make up a lot of these provide like, lot of the providers out there are solo practices, and they don’t have the capacity to bring all these tools to bear or to negotiate with insurance companies. And and so a lot of the times, like, someone looking for care and using their insurance isn’t able to find that provider. And so we have created a system systems that allow providers to take see the clients that kinda wanna come to them. They wanna take care of people and allows clients to see providers that are able to take care of them and to use their insurance to do that. And so that’s really the the goal of Sound of Mind. In order to do this, we we’ve had to challenge a lot of assumptions about how how this would work and re really support the relationship between the providers and the clients and help negotiate on behalf of the providers to all the institutional support that’s needed to really deliver care using insurance benefits because there is many providers will stop taking an insurance company or or not seek out additional ones because of the administrative burden. So we shoulder that burden for them and allow them to get back to doing what they really wanna do, which is providing care. So on the next slide, that at at scale, what this looks like is we’ve got over sixteen thousand providers spread across the country. There’s virtual. There’s in person sessions. This we have a ton of quality checks built in to make sure this this is right and have been investing so much in our own technology around AI provider tools so that providers can really truly focus on the work that they wanna do. In terms of access, we maintain this on a very, like, tight basis so that we know that when someone wants to get seen, they can get seen really quickly. I mean, they need to be like, there’s a moment of bravery, I would say, last for a very brief window for folks who are trying to seek behavioral health care. And so we need to be able to strike when they have that moment of bravery and when they’re feeling that support to be able to reach out and ask for the help that they need. Sometimes somebody might not want all of the all of the offerings of therapy. They might just need some digital health tools, and so we have AI self care tools for for clients that are client facing. The providers can also use in between sessions with clients. So because the clients are really doing the work, the providers are just helping to guide them. And we measure and track symptomology using standard measures that are patient reported so that we can see how quickly they’re getting to a subclinical level for their symptomology. And in general, it takes about seven sessions. In terms of scale, we’ve delivered over five million sessions. That’s that growth has been really, really fast, and we’re up to about a hundred and thirty thirty thousand sessions a month. We’ve covered a large, large, large volume of the population, which is about half of the country via health plans and network contracts. And we’re deeply integrated with payers, health systems, government, other strategic partners because we want to be able to make sure that we’re seeing these outcomes, but also the other systems that they’re connected to are able to share in these gains and have the visibility into who’s actually being successful in care. Thank you. Thank you so much, Wes, and thank you to all three, of our partners that have joined today. What’s very exciting now is in in just a few moments, Delaney will showcase what this looks like in FindHelp, as an option for many organizations. But just before that, one other thing to share. Working with any one of these networks or your own or others is not mutually exclusive. How this would work in practice is based on the type of organization you are and the population you serve. Perhaps you are a safety net hospital system like Parkland or BMC, or perhaps you’re a payer that’s specifically serving a Medicaid population. You may want access to the largest possible network of Medicaid accepting providers, and that may be a combination, of those you see here or others today, and that’s perfectly okay. The control over that network, is entirely within your reach. Another example, perhaps you are a national payer and you offer commercial, Medicare, and Medicaid lines of business. You may want to work with multiple, networks that really provide the best fifty state coverage, for your populations, and that is perfectly okay as well. And lastly, perhaps you, serve a commercial population as a health system or an employer, and you may want to really focus on contracts that already exist with a large network, and one or more of these partners may be best to serve that arrangement as well. So there’s flexibility built in to how you may work with one or more partners to achieve the network reach, that you have, you know, for your organization and for your population. And that is a bit of secret sauce as we go forward for what’s possible in this network access approach. I’ll turn it back to Delaney. Awesome. Thank you. This is talking about the problem to really showing how we are solving it. So earlier, we discussed the need for a unified search experience, and this is really what that looks like in practice. So allow me to introduce you all to Find Help’s advanced search. Advanced search allows navigators to search across both social care and behavioral health in a single workflow. So instead of treating needs as a separate problem that requires separate searches, we bring them together into one coordinated experience. So a navigator can actually enter social care needs like food assistance or food pantries nearby while also specifying behavioral health needs such as anxiety, depression, the treatment type, or focus area. Insurance coverage, location, and out of network preference are also factored in at the same time. This really matters because people because real people don’t experience these needs in silos. So by matching on need, coverage, treatment criteria simultaneously, we will reduce guesswork and save navigator time. So this isn’t truly just about expanding the network. It’s also making access more intentional, coordinated, and efficient. So now we’ve transitioned to the results view, so after that advanced search has been submitted. And this is where the flexibility really becomes clear. You’ll notice that the results are actually organized into two different tabs, social care and behavioral health. This allows navigators to move between domains without actually starting over. So the search context at this top will stay intact, but the results and filters adjust based on what tab they’re in. When you’re in the behavior health tab, for example, the filters shift to reflect clinically relevant criteria like therapy type, focus area, visit preference. There’s also clear signals on those listings, such accepting new patients, which we know is one of the most important factors when finding a match. If you toggle back to social care, those filters dynamically update to match that domain, so it will adapt. On the left hand side, filters can be refined at any point. Visit preference can be changed from in person to remote. And additional filters can even be layered in using the add filter, which is going to make more needs by adding without actually restarting the workflow. So if a seeker situation evolves throughout the conversation, the navigator can evolve that search in real time as well. The goal here is really flexibility without friction so navigators don’t have to backtrack, open new windows, or rerun separate searches. And the final page, so how we are actually closing the loop. Up until now, we’ve talked about search, filtering, and matching, but access doesn’t improve unless something actually gets on the calendar. This final step shows how a navigator can request an appointment directly through our platform. Availability is being pulled in through our partners, that we just heard about today. So the times being displayed actually reflect real time scheduling data, not just static office hours. The navigator can confirm client details, review the appointment summary, and submit the request without leaving this workflow. This is important because one of the biggest inefficiencies is in behavioral health access isn’t just finding the right provider. It’s converting that match into an actual scheduled visit. So by integrating availability, we are reducing the drop off between referral and care. So in summary, this workflow, the end users will be able to start an advanced search indicating both behavioral health and social care needs. Coverage and out of network preference is also indicated. Once search once searching, dynamic filters can be applied to further add inclusions or exclusions based on what they’re looking for. And once finding a match, if the provider has set their availability in one of our partners’ platforms, navigators will be able to directly book that appointment. Perfect. So now we’re going to jump into a panel discussion with our partners today. So I’m going to start off with a round robin question, and I will start with you, Lindsay. From your perspective, what is the single biggest barrier to timely outpatient behavioral health access today? Finding the people who actually have availability and are ready to see clients, that mismatch between who’s available and who needs it is one of the hardest things, I’ll say, having experienced it personally, having seen it also on that side, right, of, you know, technology and what we can do to ensure that availability is clear and we know who is taking someone today now at this time. Great. Mackenzie or West, did you wanna add to that? Yeah. I I think that it’s honestly, some of it’s hope. It’s just the client needs to have hope that they’re actually going to be able to find someone that does what they want and can see them and will see them. And and so trying to make sure that we’re sending them and connecting them with providers that do what they want to do, have experience addressing their concerns and their population, and and are able to actually deliver results and that they can actually get better. Like, that it is it is not uncommon to hear for us to hear stories about someone that’s tried multiple times and has done sent, like, twenty emails out to, like, people that never responded at all. And so the like, going from that to being able to have a list of providers, all of which they have availability in the next couple days to be able to see you is and to do what you want them to do is is is really a huge difference. And and I think that that really sparks that hope because without that hope, they’re not gonna take that leap into scheduling and trying this. Therapy’s hard. It can be scary if you haven’t done it. So I think that they have to have that hope. I think just to echo what Wes and Lindsay was saying, you know, it’s a really brave first step to say, okay. I’m ready to get help. So it’s Mount Everest one, and Mount Everest two is actually connecting to that care. And one of the important things is knowing that the providers have availability, like Lindsay and Wes mentioned, but also making sure, depending on what criteria that you’re actually trying to match on to the specific needs of the patient? Were they just discharged from the hospital? Does that provider actually take patients who have been discharged for psychosis? Not all providers do, and there’s no way to tell. Just saying they’re a clinical psychologist isn’t going to guarantee that they even treat that type of patient. And so having the granularity of filters that I know that Find Help is building into this platform is really, you know, something you might not think about topically, but when push comes to shove and you’re trying to get that referral in, it’s gonna be mission critical. Great. So really making sure there aren’t road bumps along the way when getting access to someone, especially since we know that first leap of knowing that you want to get help is really such a big one to begin with. Mackenzie, I have a question for you now. You talked a lot about how, you know, where you work with partners and organizations today, you’re taking a bunch of different types of lists that they may have, maybe Excel or paper, whatever it may be. What changes when organizations move from static list of providers to really a deeply vetted referral ready network? Great question. So I would say that there are three main things that are gonna change. The first is going to be speed, your confidence with that referral, and then outcome. So with speed, with a static list, if staff are gonna spend between thirty to sixty minutes, calling down a PDF or a spreadsheet, like what Wes was saying, checking who’s accepting patients, who takes specific insurance, or who can see someone that is recently discharged from the hospital. But in a vetted network, that work’s already been done for you. So you know that availability, intake criteria, specialty filters are current, and that you can actually search on them, that those filters are in Find Help, which they’re going to be, so that you can make those actionable referrals. So then you can expect referral time to drop down to minutes instead of thirty minutes, two hours. And the second would be confidence. A static list is a guess. No one knows when it was last updated, case managers are gonna hesitate because a bad referral erodes that trust with patients. And in a referral ready network, providers have recently been confirmed that those key data points, you know that it’s documented in the system. So that way that you’ve confirmed that they’re accepting new patients, that they treat certain populations, that they are actually in network without insurance and accepting patients on those panels, they have the right clinical focus and those intake timelines if you’re thinking about more residential treatment programs or more programmatic types of behavioral healthcare. And that’s gonna reduce those failed referral rates and that you won’t need to do those repeat outreaches anymore because those referrals are actually gonna go through, and you’ll know that because it’s confirmed by the Find Help system. And I would say the third is accountability. You know, static lists don’t have any feedback loops. There’s no systematic way to know which providers respond, which ones hold discharge slots, which ones are routinely declining certain types of cases. In a vetted network, you can track engagement and attestation cycles. And so that’s gonna support your CMS directory requirements and also give organizations really defensible process. Thank you. And I know that, Mackenzie, your team has been absolutely critical in helping us to really define some of those most needed filters within find help. So really appreciate all the collaboration that you’ve provided there. My next question is for you, Lindsey. Would love to get your take on this, especially as being a clinician yourself. Where does friction most often show up between referral and the first appointment, and how can technology actually reduce that? I love this question, and the answer is so many ways, but I’ll keep it to a few of the the major ways that we see some of that fall off happen often. Again, having having worked in the field and seeing where some of these things fall from referral into someone actually becoming engaged with care. Right? Not even just that first appointment, but truly being engaged in care. I think one of the most important things to consider and to think about when we see that referral moving into an appointment, because that’s the goal. Right? The referral isn’t meaningful until we know that connection has really happened, is the fact that motivation is not static. So when we see someone who’s working with a case manager, who’s working with someone in a system and is saying, I’m ready. I wanna take that step towards care. It’s important that they have the ability to make some of that step in that moment. When I think back to, you know, some years ago, when I was working within health systems and thought about the times that what I did hand to people, unfortunately, would be a PDF of a list of here’s people. And I’d sit and call with them, and the number who were closed to practice didn’t take the motivation goes down. So, again, knowing that motivation for a client themselves is not something that we can assume just because they’re motivated in the moment. They will continue to be motivated. Giving that piece of they can make an actual step forward when they’re feeling it is important. So where does technology come in? A whole host of ways in this. I think one is although we know that a warm handoff itself in the most traditional way isn’t always scalable, technology makes that more scalable. Right? It allows that connection between systems to know that this is someone that you trust in this moment, client, you’re working with someone, case manager, whoever it may be. You trust them, and they’re making that step with you to say, we’re gonna schedule you to this online appointment. Right? We’re gonna get you this appointment for whether it’s in person or virtual, but we’re gonna get you scheduled. It’s a technology way that actually does scale to show, like, a true translation of where you are to that next step. I also think a whole lot of the other reasons that it falls off that technology can answer is referrals used to be just that, a phone number. You didn’t have information as a clinician. Client didn’t have information about that client, about that clinician. So you were making guesses if you were a right fit. There’s a reason that even that one session is our modal number, the most common number of treatment sessions we see people occurring, is because that match wasn’t there. Having that information, allowing, like we do with technology on simple practice, clinicians to build those intake questions that are important to them that get answered in advance so that they can say before someone shows up, here’s, you know, here’s why we might be a great fit. Here actually is my colleague who even is better if this, information I’ve gathered is not a right fit so that someone doesn’t lose that motivation as they make that first step. They can actually, again, translate it along and hopefully have found that right fit through that active information, active engagement. Client portals is something else that we engage with in simple practice, which is giving clients voice to seeing where things are in the process, communicating with that therapist they’ve connected with. I think each of those and many more, I will keep to those few key ones, but I think there are many ways in which technology eases those previously very manual and difficult to scale processes that we know work in the past. Yeah. Thank you so much for your add something to that, Delaney? Because Yeah. Of course. The piece where that meets with what Mackenzie just spoke about, and Lindsay was absolutely right, is that these therapists, they want to do great work. They wanna take care of people, but they they have a niche. They do they there’s a things they do really well. Not everyone does everything really well, and so they don’t want the referral. They don’t wanna say no. They don’t they want the referrals that do that highlight their strengths. And, like, this is an ability to where we can match a client need with a provider’s, like, where their passion is, that’s the sweet spot. That and that really, like, drives all of this home. And so the ability to use the sort of the front end tools and the communication and all those technology and then getting those referrals to the right person is is so crucial for both parties. Yeah. I love that. Thank thank you both. And, Lindsay, I I really loved what you said too of, you know, maybe you’re not the right match for me, but I do know someone else or another colleague. And I think that’s, you know, not necessarily even a technology piece, but it’s about the communication and the relationships even within the provider networks as well that is so important. Wes, I have a a question for you. Would love to understand how do you measure whether a behavioral health network is truly perform performing beyond just the provider count? Yeah. So, obviously, if you don’t have providers, the odds of being successful are pretty small. So start there. And then we’ve talked about this and this is a step where we you you have to get clients connected to those providers. If that initial conversation doesn’t happen, if that first session doesn’t happen, so get doesn’t that doesn’t work. And I’ve never yet, Howard, anyone say that they wanted to go into therapy to have one session or just to even to be in therapy. That’s not why anyone goes into therapy. And so we need to get them engaged. And so that means for us, we’re we’re looking at our providers that are getting clients to, like, that third session within thirty days. There’s getting that cadence going. Therapy takes work. The first sessions are a lot of questions and then, like, really getting into the work and helping folks deliver on the results. But even if I get you to engage in care, that’s not why that’s not why I would go to therapy. That’s not why I’ve been to therapy. It’s because I wanna have seems I wanna see changes. And so we use standardized measures for most major diagnoses to track are is are these clients saying that they’re getting better? And that allows us, one, to track this over time. We can share we can share this on a graph over time of, are you delivering this for each individual client, and are you delivering this for your caseload at large? And then as as an organization, are we delivering this for the entire population? And so that helps us identify where some providers might need help or might need a guidance because to like, with McKinsey’s work, if we aren’t telling if providers aren’t the best judge of who they’re actually really good at working and serving, they may think that they’re amazing with this population or this diagnosis, and maybe they’re not. And this allows us to have some of those structured conversations with them around you’re saying this, but, like, the data is showing a different thing. And so how do we how are we able to, like, follow-up with them and really help them shape that? And so we really index on, are people getting better? Are they saying that they’re getting better? And do they trust the provider they have? After every session, we ask follow-up questions. Do you understand your treatment goals? Do you trust the provider? Do you feel seen and heard by like and if the answer to those isn’t all an absolute yes, we’ve sent that back to the provider so they can address that in the next session. Because at the end of the day, the relationship between the client and the provider is the most predictive factor for someone improving and getting better. And and that’s our entire system is built around maximizing that and delivering that relationship. Excellent. Yeah. I I love that idea of actually having some of those immediate feedback loops, you know, right after a connection has been made. That’s great. One final question here for our panelists. This one’s gonna be for you, Joffer, before we get into the q and a. So we’ve discussed a lot today, the curation of providers, the navigator workflow, and network performance. How do we really bring that all together into one cohesive experience for our care teams? Thanks, Delaney. Appreciate it. Thank you to the panelists for sharing all of your thoughts. One would think that we had made more progress in this country on accurate, you know, data about the provider networks. I am excited to share that CMS, Center for Medicare and Medicaid, is working on a national provider, directory initiative. They’re focusing on medical providers outside of this space to start, but it’s exciting to operate in parallel and hopefully make some significant progress as CMS is working on similar challenges. So a few things to share. One, we do have to respect the rules about privacy, especially in areas such as behavioral health. Those of you that work in this space every day are familiar with what’s called forty two CFR Part two, which is, you know, laws related to keeping information secure and private in the behavioral health sector, including others. Find Help is a HITRUST certified HIPAA compliant platform that also respects forty two CFR. But more importantly, customers have the freedom and control to choose what information is shared as part of a referral or an appointment request. And so customers are still in control, over their compliance at the state level for sharing individual sensitive information, and that is very important to make this successful. Secondly, our work with these three partners, includes the ability to have closed loop information, and it will be up to the partners here to help determine what information comes back. For example, did the individual show up to an appointment? Was there a no show? Were they satisfied and or received, potentially recurring appointments? And that data point is valuable. Not necessarily, the treatment notes and and other protected data, but the fact that an individual is engaged complements the longitudinal health record for the primary clinicians and those that have initiated that referral from the health plan or the hospital system or others. So that longitudinal record is also something that we’re working to solve. So I think we’re on the cusp of something really meaningful, which is beginning to digitize, the behavioral health networks in a way that brings, accurate data to the care teams that are initiating many of these requests. And I think that’s a powerful piece of the work we’re kicking off together. I’ll turn it back to Delaney, and, happy to answer any more q and a questions as they come in. I’ve been answering many of them just in the chat, real time, so hopefully that’s been helpful for teams as well. Great. We’ll pull back up our slides real quick. Okay. So, hopefully, everyone is very excited about this announcement of the Behavioral Health Specialty Network. You guys can actually go ahead and start letting us know when you’re interested or how how deeply interested you are. I’m gonna give everyone a minute here to pull out their phone and and actually scan the QR code, But we will have a behavioral health network interest form that all of those on the line today can actually fill out. We will have some opportunities for some early access and even product influence for those that are interested in contributing the shape of this early on as well. Believe that link was also in the chat if you’re not able to scan the QR code. K. Going to our last couple slides here. So some of the frequently asked questions that we were anticipating and already looked to see several of these coming in through the chat already. The specialty network is an add on network. So if you are a customer, please talk to your customer success manager or account director to learn more. If you’re not already working with Findhelp, please reach out to your sales team to learn more as well. In terms of actually contracting with for the specialty network, all the contracting will be through Findhelp to access the My Resource, SonderMind, and Simple Practice networks. They’re not going to be mutually exclusive, so we can work with you and your existing networks as well. And then the third FAQ that we were anticipating is compatibility with integration. The first iteration that’s coming out end of q three, q four will be compatible with launch integrations to start. And with that, we’ll open it up to q and a. Joffer, if there’s any questions that you’re getting often in the chat, please feel free to reiterate those as well. Sure. So I think some of the questions that we’ve been receiving is, is there flexibility, to determine the breadth and depth or scope of a network that a customer may want? Absolutely. That’s part and parcel to the approach that we’re taking is, you may want, for example, Medicaid providers in a single state as a MCO health plan, or you may want, for example, nationwide coverage as a national health plan or as an employer. So it’s very important that you have the control. You may also have your own list of providers that you may want find help and or one or more of our partners to ingest and map and understand the overlap and improve the accuracy of that provider network as well. And that’s something I think many of our partners are interested, in supporting as well. And then another important question is, it takes more than just knowing, for example, that they accept Medicare Advantage or they accept Medicaid as a provider. We need to know the specific plan. Many states have sometimes three, four, or even ten managed care organizations for the larger states. And the answer to that is yes as well. We will be, tracking, the coverage that’s specific to the MCO plan for as many providers as we can, and much of that data will be sourced from those that you see here with us on the call today, and in some cases directly from those providers through our customers as well. One other important question. Will this behavioral health network be available on the member facing FindHelp sites, or as we call them at FindHelp, the community facing sites? We are considering this. We we do want to make it possible for individuals to search through a provider network in privacy and and with that dignity on their own, but we’ll likely explore that as a phase two. We’re looking at phase one as facing the staff of your organizations as they’re working on, matching and and scheduling. And more to come from Delaney and team, you know, over the next few months on on that approach as well. And, Delaney, I’ll turn it back to you. Okay. Looks like all of the q and As have been answered, directly as well. I did see a question come in about how a solo therapist may get connected with Simple Practice or SonderMind. I think we can send out some of the their information as well with this webinar for those that may want to get in contact directly with them too. Alright. So thank you all so much for joining us this afternoon. If you have any additional questions or any follow ups, please feel free to reach out to me. My email address is here on the screen. It’s d boldman at find help dot com. Of course, you can always talk to your customer success manager or account director as well that are, that you’re working with, you know, on a weekly basis or monthly basis. So we’re happy to answer any questions that you may have coming out of this. Thank you all so much for joining, and have a great day. Thanks all.

**What’s next for No Wrong Door?**

“Closing the Behavioral Health Gap” is available now—Episode 9 will be released on June 10 and features Alex Reed from Denton County Public Health exploring how collaboration, trust, and data can transform how communities connect people to care.

Subscribe to No Wrong Door wherever you listen to podcasts to be notified when new episodes drop:

At Findhelp, we believe that technology is only as powerful as the people driving it. That’s why we created the 2026 Community Contribution Award to honor individuals at our customer organizations who go above and beyond to transform how their communities access social care.

This award celebrates leaders who embody three core pillars: exceptional contributions to the network, a deeply collaborative spirit, and an innovative perspective on solving complex challenges.

For 2026, we are incredibly proud to honor three phenomenal leaders who are setting a new standard for social care across the country.

PCA Georgia + Find Help Georgia

Fostering intentional community relationships

Building a digital resource network is one thing; getting an entire state to actively use it is another.

As the Find Help Georgia Manager, Kimberly has been the driving force behind Find Help Georgia since 2022. She understands that true community engagement requires meeting organizations exactly where they are.

Kimberly Stewart-Lucas of PCA Georgia and Find Help Georgia is a Findhelp 2026 Community Contribution Award winner!

“I am so grateful to have been part of the Find Help Georgia journey with Kimberly Stewart-Lucas. The passion she brings to every aspect of her life and work is unmatched and is a large part of why she has been so successful with Find Help Georgia’s community outreach. Anyone who has been to one of Kimberly’s training can attest to how dedicated she is to making sure communities are connected. Congratulations to Kimberly and her whole team!”

Kelsey Allen

Associate Principal of Customer Success, Findhelp

By conducting more than 60 formal training sessions and showing up as a tireless advocate at community forums, Kimberly has woven the platform into the fabric of Georgia’s safety net. Thanks to her efforts, over 20% of all program claimings in Georgia now originate directly from the Find Help GA site.

Hello, everyone. We are excited to have you join our presenters to hear more about how Find Help Georgia has been shifting and evolving in their collaborative work. My name is Kelsey Allen, and I have had the pleasure of working with our presenters today on their Find Help Georgia collaboration since the very beginning. I’m an associate principal on FindHelp’s customer success team, and I work across our customer organizations to help them incorporate their FindHelp platform into overall social care strategies. But first, some housekeeping tips. This session is being recorded, and you’ll get access to those recordings on Friday, May fifteenth. So don’t worry if you miss something, you’ll be able to see it again. And we ask that you use the Q and A tab at the right side of your screen, and we’ll do our best to answer questions at the end of the presentations. When we first began working with Georgia Department of Early Care and Learning and Technical College System of Georgia, it was to support the 2Gen work, which you’ll hear more about from Melinda. Around that same time, Positive Childhood Alliance of Georgia was approaching us as well for a way to connect families to resources. Given the overlap in the populations that all three organizations were serving, a collaborative was formed with a specific community facing site, Find Help Georgia. This is also my favorite little Easter egg. PCA Georgia had already decided on and gotten the URL for FindHelp Georgia, while FindHelp as a company was still Ann Bertha and just beginning our own rebrand to FindHelp. With this collaboration, the three organizations worked out a shared governance structure that allows each group to work to its strengths. For those of you who have attended past Connect Summits, you may have heard Kimberly speak in twenty twenty four about Find Help Georgia’s successful work in engaging CBOs and programs. Because of the work of Find Help Georgia Collaborative, they’ve seen tremendous success in getting Georgians connected to programs across the state. Since twenty twenty two, they’ve held over sixty two CBO trainings and had over eight seventy attendees. But as the landscape of nonprofit organizations, funding and needs change, our Find Help Georgia partners have also continued to evolve their approach with their platforms. With that, I’d like to bring up Kimberly here to speak more about that evolution. Kimberly Stewart Lucas is the newly promoted Find Help Georgia manager at Positive Childhood Alliance of Georgia, PCA Georgia, formerly Prevent Child Abuse Georgia, which is housed in the Mark Chaffin Center for Healthy Development within the School of Public Health at Georgia State University. She leads the Find Help Georgia program efforts through training, technical assistance, and community engagement outreach to providers and those seeking help. Along with annual conference planning, administrative marketing and logistical support, Kimberly also provides mandated reporter and supporter training. Kimberly has a passion for event planning, curating art exhibits and wellness workshops. She’s an advocate and an educator for natural and home birth, and she receives joy in bringing people together, providing valuable resources and creating lasting, meaningful memories that inspire and educate. Kimberly, we’re so grateful to have you here to talk more about PCA Georgia and Find Help Georgia. So I’ll leave it to you. Thank you so much, Kelsey. I’m so glad to be here and join you all today for this presentation. So what we’re looking at right now, this visual, the Connected Communities Model, is about making access to help simpler, faster and more coordinated for the people that we serve. So at this center are the organizations powering this work. And as Kelsey mentioned, that’s PCA Georgia, DCAL and TCSG, where state agencies, community based organizations and partners like Find Help Georgia, again working together instead of in silos. Surrounding that core is the full ecosystem that touches a family’s life, Schools and colleges, health care providers, law enforcement and first responders, courts and legal systems, local government, businesses and community organizations. And just as important on the outer layer are the people we’re all here for, children, families and individuals navigating real needs like childcare, education, food access and safety. What this model does is connect all of those touch points into a shared system. So instead of families having to figure out where to go next, the system works around them. And that’s where Find Help Georgia plays a critical role. It enables a true no wrong door approach and experience, whether someone enters through a school, a clinic, a helpline, or on their own. They’re connected to the same up to date network of resources. It also supports self navigation, which reduces pressure on the frontline staff while empowering others and individuals to find help in real time. And behind the scenes, it gives us something we haven’t always had, shared data and analytics. So counties and agencies and health plans can align their efforts, measure impact, and improve outcomes together. And finally, this isn’t just a technology solution. It’s infrastructure for collaboration. It strengthens relationships across sectors, it builds trust, and allows communities to organize around what communities need, not just what systems are designed to provide. So I want to ground us now on how we got here and why this work matters. So at Positive Childhood Alliance Georgia, again, formerly Prevent Child Abuse Georgia, our work started many years ago with the one-eight hundred Children Parent Support Line. The goal has always been simple: support families early before challenges become a crisis and connect them to the resources they need for healthy outcomes. Because when families have access to concrete supports like childcare, food, education, we reduce stress and strengthen family stability. And importantly, we see this as universal. Every caregiver at some point needs support. So what you see on this timeline is that evolution. We began with the phone line in nineteen eighty two, expanded later to a staff helpline, then onto an online resource map, and helped shape statewide prevention efforts like Georgia Essentials for Child Care and the Georgia State Prevention Plan. But even with all of that progress, a core challenge remained. Services were still fragmented, hard to navigate, and often to the people who needed the most. So we asked, how do we make access simpler, more equitable, and easier to trust? And that’s what led us to find Help Georgia. So in about two thousand and two or ‘twenty two, through cross sector collaboration with the Georgia Department of Early Care and Learning, known as DCAL, and the Technical College System of Georgia, also TCSG, and PCA Georgia, we built a shared platform grounded in a few key priorities, making it easy to search and find help in real time, allowing for anonymous self directed access, reducing stigma around asking for help, and ensuring that information is accurate, accessible, and available across languages and communities. So Find Help Georgia is the result. It’s a centralized statewide network that connects individuals and families to free and low cost services in their own communities. Just as important as the tool is how we work together behind it. So as partner agencies, we’ve aligned around a shared community community facing platform, while also supporting our internal teams, reducing duplication and expanding reach through our collective networks. We’ve also formed a formal governance structure to guide decision making, maintain alignment, and support long term sustainability as more partners join this work. As we look ahead, one of our major next steps is strengthening the connection between digital access and human support, particularly through the evolution of the helpline, including its transition and expansion with PCA Georgia at Georgia State University. So ultimately, this is about creating a system where no matter how someone enters, whether it be the phone, the website, or through a trusted partner, people can find help quickly, safely, and with dignity. So in just two months last year during the busy holiday season, our team successfully transitioned and relaunched Find Help Georgia’s helpline under PCA Georgia, and we relaunched it this year, February second of twenty twenty six. So during this extensive onboarding period, staff were trained to confidently answer helpline calls, to learn how to navigate successfully through the FindHelp Georgia platform, provide meaningful referrals, and build a curated favorite resource folders to improve response efficiency and consistency. The relaunch process required continuous learning, still does, flexibility and collaboration. Through ongoing trial and error, we refined workflows and partnered closely with Kelsey to make sure that multiple updates to the call intake assessment form to do that so it’s better reflecting the caller’s needs and improved data collection for what we need for our reports. As the helpline continues to evolve, we’re also excited to participate in Find Help’s call center early adopter program, helping test new platform functionality and features that strengthen the user’s experience, improve the referral process, and support more effective communities and connections across Georgia. So since transitioning the FindHelp Georgia platform earlier this year, we’ve gained valuable real time insight into what access to care looks like on the ground, not just in theory, but in people’s lived experiences. So one of the biggest takeaways has been identifying where the gaps truly are. While the platform includes thousands of resources, we’re seeing some pockets in areas like affordable housing, childcare availability, and culturally responsive services. And these just aren’t data points. They show up as longer searches, repeat callers, and limited referral options in certain regions in Georgia. Another key lesson is the importance of organizations actively claiming and maintaining their listings. A resource is only as helpful as it is accurate. When organizations take ownership of their information and their program cards, we see stronger connections, better outcomes, and increased trust in the system overall. We’ve also seen how powerful seeker empowerment can really be. Many individuals are using Find Help Georgia to self navigate on their own time, in their own way, and often anonymously. That autonomy reduces stigma and allows people to seek help earlier before challenges escalate. And finally, this work has reinforced what authentic community impact really requires. It’s not just about having a platform, it’s about ongoing engagement. So listening to communities, building relationships with providers, and continuously improving on the network based on what we’re seeing and hearing. The helpline just doesn’t connect people to resources. It gives us a feedback loop. And that feedback is helping us strengthen the system to be more responsive, more equitable, and more aligned with the real needs of Georgians. So another big lesson that we’ve learned in this whole process with Find is having the platform is not just enough. Community engagement must be intentional and ongoing. And these are some of the ways that we suggest that customer branded Find Help platforms can increase awareness and trust and actual utilization with their communities. First, we offer regular virtual workshops and live demonstrations that help community members and partners understand how to use this platform more effectively. Many people don’t realize how detailed and searchable the resource network is until they actually see it in action. Another strategy is helping partners partner organizations embed the Find Help search box or directly link until they’re on websites. This increases visibility and makes access easier for families who already trust and visit those organizations online. We’ve also learned how critical it is for organizations, again, to claim and regularly update their listings. An outdated resource creates frustration, we know this, for seekers and referral partners. So encouraging community partners to maintain accurate information strengthens the overall ecosystem and improves trust in the platform. So beyond awareness, staff and community partners should actively use the platform in their interactions with families every day. Not just refer people verbally, but walk them through Find Health Georgia or Find Health platform in real time when possible. That helps empower the seekers to use the tool independently in the future. The mobile app is another underutilized engagement tool. Encouraging downloads gives users easier access to resources directly from their phones, especially for people navigating urgent needs while on the go. And finally, promotion matters. Easy to share flyers, social media graphics and content, QR codes, newsletters, and community outreach materials all help normalize the use of the platform and expand reach into the community. The more visible and integrated the platform becomes across organizations and systems, the more likely people are to use it with trusted entry points and care supportive services. So I would like to thank you all for this time and the opportunity to share our experience in how we’re growing Find Help Georgia. We are really excited about how we can continue the opportunity to strengthen community connections and improve access to social services across Georgia. And now I’ll turn it back over to Kelsey. Thank you so much, I loved hearing all the work that you guys have done, the evolution of Find Help Georgia. Now, I’d love for you all to take a second to answer a poll that we’re going to put up here on screen and in the chat so that you can answer and tell us where have you seen the greatest need to evolve in your organization, whether that’s through the mindset of staff and how they’re addressing resource needs, how you’re engaging CBOs, the various populations that you’re serving, and maybe that has evolved for your organization. Or if there’s anything else, please tell us in chat. We’d love to hear from everybody here. Wonderful. We’ll give folks a minute or two to answer that. And as we have you answer that poll, we’ll be moving on to talking a little bit more about how DeCal has used Find Help Georgia as well. All right. Alright. Okay. You haven’t had a chance to answer that poll, feel free to put in chat more about where you’ve seen evolution. And I’d love to introduce you to Melinda to speak on how Georgia Department of Early Care and Learning is participating in Find Health Georgia. Melinda Knowles serves as the Development and Partnerships Project Manager for the Child Care and Parent Services or CAPS division of DeCAL. In this role, she leads cross sector initiatives that promote whole family well-being and economic mobility through the 2Gen approach. Melinda oversees the CAPS provider and family advisory councils, ensuring that the voices of families and providers shape policy and program decisions. She also leads DeCAL’s engagement with Find Help Georgia, helping connect families and early learning professionals to vital community resources. She’s played a key role in shaping how Find Help Georgia is used across the state, making sure it reflects real needs of families and providers. With a background in education and workforce development, including international experience, Melinda brings a practical, people first approach to systems change. She’s especially committed to ensuring families have a voice in programs and policies that affect them. Melinda, thank you so much for being here, I’m excited to hear more about what DeCAL is doing with Find Help Georgia. Thanks so much, Kelsey. I’m happy to be able to share today. Good afternoon, everyone. As Kelsey said, I’m Melinda Knowles and I work with DECAL, the Department of Early Care and Learning here in Georgia. And at DCAL, families come to us for childcare, but we know childcare doesn’t exist in isolation. Employment, education, nutrition, housing, all of it intersects. And Find Help Georgia gives us a way to acknowledge that reality without expecting families to navigate siloed systems on their own. We have five different divisions at DeCAL, each focusing on a different aspect of early care and learning. And we focus not only on early care and learning, but we also address nutrition and social emotional support among other areas, and that includes helping pay for childcare. The role of CAPS at DECAL, and CAPS stands for Child Care and Parent Services, is to facilitate child care scholarships for those families that are in financial need. As we all know, resources are limited, so CAPS has established priority groups to help us ensure that the most vulnerable families receive that support that they need. And I wanna talk today about one priority group we chose to focus on in a pilot program, student parents. Research shows that education can help generational outcomes, but not having the resources to complete education, basic necessities plus childcare, means that that opportunity is often lost. And that’s what led us to launch our student parent pilot. We were hearing from student parents who were doing everything right. They were enrolled in school, working toward their credentials, but they were still at a risk of dropping out. Accessing things like childcare, food, and transportation felt overwhelming to those families. And we saw them doing the hardest work. They were trying to connect all of these programs that weren’t designed to talk to each other. And at the same time, our staff were burning out. They were acting as informal navigators across multiple systems instead of focusing on helping families reach their goals. Families were running multiple online searches trying to figure out which program fit their situation and whether they were eligible. And often this meant repeating their stories several times. And even if they found a good fit, the programs might be full or temporarily closed. And Kimberly alluded to that in her presentation, talking about the resources not being up to date. Find Help Georgia addressed many of these barriers by putting all of the resources in one place, and it allows families to filter by eligibility and availability. Knowing that student parents needed more than just child care to succeed, Find Help Georgia became a key tool for connecting families to broader supports. The student parent pilot wasn’t about creating a new program, it was about changing how families access support. For the pilot, we placed CAPS consultants on Technical College System of Georgia campuses around the state, embedding them where student parents were already engaged in education and training. Typically, families will connect with CAPS by phone, but by being on-site, it allowed for warmer, more consistent support for those student parents. Our consultants introduced Fine Help Georgia and assisted with navigation as needed, but they also allowed families to self navigate. And this shift created space to focus less on searching for resources and more on long term outcomes. Now we would like to share a short video that highlights two of our CAPS consultants for the student parent pilot that are based at Wiregrass Technical College in Valdosta. Hi, my name is Carla Berlioz and my name is Larisha Simmons and we are at the Wiregrass Valdosta campus. We are consultants with the CAPS two Gen student parent pilot program here. At our Wiregrass Valdosta office we have set aside a help desk station where we have pamphlets, handouts, and a Find Help Georgia caps, kiosks for applications and searches. So, within this desk station, we do allow our two gen student parent consultants to know that there are additional resources for food if they do need additional food stamps or food banks, housing for a low income or energy assistance program, childcare, additional funding if they are denied for any reason. Also, health care parenting support and then also legal advice among many other resources. Find help Georgia. Follow us. When the Tugene student parents do come in, whether eligible or not, we also tell them about the Find Help Georgia program that we do also partner with. While the Find Help Georgia program, they’re able to go on to the link or the website, type in the desired zip code as well as it’s within anywhere within Georgia and see additional resources or funding that is also able to assist them in their day to day life. So what we’ve learned, by making targeted changes to how information was organized and shared, staff gained faster access to verified local resources, cutting down on time spent searching or double checking information. We also reduced duplication and confusion by ensuring everyone was working from the same up to date source. That clarity directly boosted staff confidence, especially with real time updates that reinforced they were sharing accurate information. And on the family side, the impact was just as important. With clearer, more reliable options, families felt more informed and more in control of their choices rather than being overwhelmed by uncertainty. Overall, these weren’t large system changes, but they showed how thoughtful adjustments can meaningfully improve both staff experience and family outcomes. But those improvements didn’t just happen because we turned on a tool. We quickly realized that to see these benefits consistently, we had to change how we were working. This required a mindset shift from being fixers to connectors. In our field, it is natural to want to solve everything for families in one interaction. But the tool only worked when we equipped staff to confidently guide families to resources to support long term problem solving. To help support this shift, we introduced Family Centered Coaching across CAPS. This helps staff meet families where they are and focus on the goals families identified, not the goals we assumed they should have. We’ve woven the training for both Find Help and Family Centered Coaching into our onboarding of new staff as well as offering refresher training to our more seasoned staff. Additionally, we stay up to date on the additional tools Find Help offers on their platform to make sure we are taking advantage of not only the best way to offer resources to families, but to help support those community based organizations whose resources are listed on the platform. Building on those experiences, this slide reflects what we learned about adapting along the way. One clear lesson was that a one size fits all approach doesn’t work. Each agency has unique structures and pressures, and our approach had to remain flexible. We also learned the value of starting small, testing ideas, adjusting based on what worked, and improving without overwhelming staff or disrupting workflows. Data and frontline feedback were essential. The strongest changes happened when paired performance and data with lived staff experience. And finally, governance and shared accountability matter. This work succeeded because DCAL, PCA Georgia, and TCSG each contributed expertise and capacity toward a shared goal, getting resources into the hands of Georgia families who need them. Those lessons shaped our internal work, but they also point to something bigger. This work matters beyond decal because shared tools enable shared outcomes. When agencies operate from the same foundation, alignment becomes easier and silos begin to break down. It reduces the burden for families and staff, Families are navigating fewer systems and staff are spending less time troubleshooting and more time supporting meaningful outcomes. It also strengthens statewide collaboration by creating a shared language and a consistent approach while still allowing local flexibility. And ultimately, it positions Georgia for a collective impact where aligned systems make it possible to create coordinated, lasting improvements for families across the state. And now I think that we will move into questions. All right, there we go. Thank you so much, Melinda and Kimberly both for sharing those wonderful experiences that you all have had, what you’ve been doing with your organizations. And love that, Melinda, about shared outcomes require shared tools. I think that’s wonderful. I know we may have some questions to answer. And so one of the ones we wanted to make sure to call out and see if Melinda and Kimberly, if you wouldn’t mind answering for us was in terms of the shifting landscape as we’ve talked about and evolving how your approach works, what impact do you think that has on the populations that you’re serving and the organizations you’ve been working with over this time? And yeah, I don’t know, Melinda, if you want to start or Kimberly, happy to put it out there to either one of you. Well, I know with our transitioning to helpline and our staff has experienced, of course, great change. Providing direct services is new for many of us. And because of the changing landscape, we are a helpline, not a crisis line, but people are in crisis right now. And so that is informing us, again, on the importance of updated listings, again, having that extended or that continued relationship with organizations to add their programs, particularly in rural areas in Georgia that may be there and they’re just not listed and people don’t know. But we’re still making those connections because we’re still finding the organizations to add. But it’s really informing us of how the challenges that people are experiencing right now and what they’re going through and just what the need is and how greater the need’s becoming for people across, whether it’s health care, housing assistance, transportation, career assistance. So it’s definitely made a big difference because we’re receiving those calls directly. Wonderful, and Melinda? Yeah, so to echo what Kimberly is saying, that lack of resources for some areas of the state, that’s something that DCAL is focused on this year is increasing the amount of resources available. That gets tricky because resources are limited. We might see some of our organizations that were offering a lot of help before closing down, having limited bandwidth but we are making it a priority this year to keep searching out more organizations to add to the platform and make sure there’s that awareness there and let them know what they can offer families through the platform and how it can benefit them as well. Yeah, and then Kimberly and Melinda, both you have had those shifts and those evolutions in like you’ve mentioned staff training and their mindset. What other than their mindset, has there been other difficult aspects or lessons learned from just shifting their responsibilities, their roles, and as this landscape has evolved? I think the level of care that we’re extending to the seekers that are calling, there is just a need. I heard another session that we need each other more than ever. And Find Help is an amazing tool. And of course, through Find Help Georgia has really been a tool for people to rely on. It could be in the middle of the night. Our helpline hours are what they are now, but it’s a tool that people can use when they’re thinking about how they’re going to pay their rent at three o’clock in the morning and the ease of access they have to those resources. So even when people call the helpline because sometimes people want to just talk to someone and share their story we like to empower them and let them know that the platform that we’re using to connect them to resources, they also have access to that twenty fourseven and it’s free to use. It’s just, again, that level of care that people need. People are really going through some challenging times right now. But to give them a little more of a push, I think Find Help Georgia really does that, to let them know that they have access to these resources whenever they need them. And the phrase from all of the materials that has always stuck with me from day one of working with Fine Help Georgia with dignity and ease that always sticks with me. And I think that it’s very important that our staff understand that and that the families who need that help understand that. And so we’re always very aware of letting them know, hey, this is anonymous, here’s this resource. If you don’t feel comfortable coming through us, you don’t have to sign in, go out on your own and get it. I think that really promoting that you can get it without giving your name to us. I think that that’s really helped families feel more comfortable to reach out for that help because we’re seeing families that typically a year ago may not have needed help, now they need help and it’s a new place for them to be and so that dignity and ease piece really just, I feel like that’s important to let those families know that. Yeah, before we move on to this question we got in chat, I did wanna just kind of call out something you said, Melinda, which was moving from that fixer mindset as somebody who also wants to solve everybody’s problems immediately. I thought that really resonated pretty well because that’s kind of where we’re at, right? And we’re not going to be able to solve every problem that we come across, but we can connect somebody somewhere with this platform. And I thought that was really well said. How was it trying to get past that fixing mindset with staff? Was that something that was like one on one sessions with your staff talking through it? Was that stuff that had come up just naturally as time has been going on? I think that all of our work that we’ve done with TwoGen and moving toward that family centered coaching has helped our staff be more aware of what we may think is the fix might not be the fix for that family because we can’t know everything in one phone call about all of the things that might be happening for that family. We only know what they feel comfortable sharing with us. Moving toward understanding, let’s ask this family what their goal is, what are they trying to accomplish? Knowing what they’re trying to accomplish, what pieces can we give to help them get there? Instead of us saying, Oh, if you get this done, then your life will be great. Maybe they don’t have the resources to go to school right now or to get that job that would give them a higher income. So really listening to our families and hearing what they need and then connecting those things. I think that the family centered coaching has really been important to help that happen. And it’s hard, we still wanna fix, even though we’ve had the training, but we still wanna fix. I think that’s hard to step away from as a human. Yeah, exactly. There is a wonderful question in chat and it’s kind of moving us around to the organizational and governance structure here. But somebody in chat asked if there was any advice on how to do what Georgia has done in this incredible partnerships in other southern states. Well, I believe Yes, please. I’m gonna say, I believe there is power in partnership. I know that this engagement team came together because we serve similar populations. And instead of reinventing the wheel and again, DeCal and TCSG already had something collaborative together. And then it was like, hey, we also serve those same populations. So to me, it’s about aligning with maybe other organizations that have similar goals and similar connections to the community. But there’s just strength in numbers and to do this work together because what we’re able to do, we do because of what DCAL is able to do. And so there’s just a synergy there and what TCSG is able to do. So we have different roles, but it covers all the areas, I think, really well in that partnership. Yeah, I think one thing to sorry, Melinda, go right ahead. I was going say, definitely, when you find those organizations that can work together the way that PCA Georgia, DCAL and TCSG have, keep in mind each organization has something different to offer based on the number of staff they have or their workflows. Kimberly mentioned all of the trainings that have been done, that’s primarily been Kimberly’s team. Despite DeCal having a much larger group of people than Kimberly’s team has, Kimberly’s handled all those trainings. We’ve taken on the outreach work because we have the numbers to make the phone calls to the organizations. So it’s really when you find that group of organizations to do the work, do what you can from each organization to create that common goal. Yeah, I love that. And I think that was one thing is finding those groups that are targeting the same areas, but in different ways, so you kind of have that blanket of care and outreach. I want to say there are also other ways to kind of find those organizations, collaboratives that exist today in your states where you’re working together with other organizations that have similar goals. And so look there as a way to start and see where other collaboratives can be put together like this one too. And then of course, I know Kimberly and Melinda both will be very happy to give anybody any advice. I know they’ve been wonderful at a lot of our other organizations who have also had questions about how to manage this sort of collaborative in the past as well. And with that, I think we’re going to go ahead and put some surveys up on the screen here in a minute. So we ask that everybody who has attended here to go ahead and take some time to answer those survey questions. And I’ll go ahead and pull them up here too. As we say, thank you so much, Melinda, Kimberly, if there’s any parting words you’d like to say here, feel free. I’m just glad that we got the band back together again. We were together in December at the summit in person here in Georgia, and this is my second time being part of the summit. So I’m grateful to be asked back and to be here with Melinda and you, Kelsey. So thank you. Yeah, so happy to get to share our work in Georgia with everyone. Hopefully it inspires some other states to put something like this together in their states. Yes, well, you guys have done amazing work. We’ve seen a lot of progress in Georgia through the Find Help Georgia work that you guys have done, and we’re really so excited that you guys were able to come on and talk more about how it’s evolved because things don’t stay the same day after day, right? We have to evolve and shift and look at what priorities come up. And so I am so grateful for you guys to be here today. And thank you, everyone in the audience as well, who asked questions and engaged with us. Really excited. Hopefully, you guys are able to find other sessions today with the Connect Summit that you can enjoy and see those different networking opportunities as well. Thank you, Kimberly and Melinda. Thanks so much, Kelsey. Thanks.

CONNECT SUMMIT 2026

Explore how Georgia’s leading agencies are transforming service access through the statewide Find Help Georgia network. Learn how self-navigation and real-time resource updates reduce the burden on families, and discover how Findhelp’s analytics and governance enable counties and health plans to advance shared accountability and collective impact.

TennCare

Leading implementation of a statewide social care infrastructure

When it comes to systemic innovation, Nicolette, the Director of SDoH, is leading the pack. She was the primary architect behind the Tennessee Community Compass—a country-leading, Medicaid-wide closed-loop referral system launched in March 2025.

Nicolette successfully united Managed Care Organizations, state agencies, and major provider networks into a single, cohesive coalition. Crucially, she ensured the network was accessible to all Tennesseans, not just Medicaid members.

Nicolette Wise of TennCare is a Findhelp 2026 Community Contribution Award winner!

“It has been such a pleasure to work with Nicolette and the TennCare team for the past year and a half. Their dedication, expertise, and commitment to Tennesseans is inspiring and will continue to lead the way in social care innovation across the country. Extending my biggest congratulations to their teams. Thank you for all your hard work to make Community Compass successful!”

Alison Steinbacher

Associate Principal of Customer Success, Findhelp

Under her leadership, the system has already facilitated tens of thousands of referrals, proving that massive state-wide infrastructure can still feel deeply personal and community-focused.

Okay, everybody. Welcome. Our session is titled Tennessee Community Compass, Tencare’s approach to a statewide CLRS. My name is Allison Steinbacher, and I’m an associate principal on Findhelp’s customer success team. Thank you for being here today. Before we get started, just a couple of housekeeping items for you all to be aware of. This session is being recorded. You will get access to the recordings on Friday, May fifteenth. If you have questions throughout the presentation today, please use the q and a tab at the right side of your screen, and we’ll do our best to answer all of your questions at the end of the presentation. With that, I would like to introduce our speaker for today, Nicolette Wise. Nicolette is the director of social determinants of health at TennCare. She works diligently to design and lead community based strategies that address the root causes of health across the state of Tennessee. I’m gonna go ahead and turn it over to Nicolette to get us started now. Hi. Good afternoon, everyone. As Allison mentioned, I’m Nicolette Wise. I’m the social determinants of health director at TennCare, ten Tennessee’s Medicaid agency. I’m really excited to be here and talk more about our find help or find help as our closed referral system, also known as Tennessee Community Compass. So here’s an agenda just to level set us for this next hour or so. I’m gonna talk a good bit about some background and vision as it relates not only to our closed referral system work, but our larger social determinants of health strategy. And then I wanna dive into some key features of our platform with find help as well as well as how we think about unifying the ecosystem to support health related social needs and then also how we’ve thought about scaling and sustainability in this work and as we look into the years ahead. Alright. So I wanna level set. I don’t wanna assume that all of us here in this group are on the same page, though. I feel pretty confident that we are. Wanna just start with this really popular tagline that health care alone is not enough. And as a public health practitioner and prior to become prior to before before I came into the, the Medicaid space, I did a lot of work in the public health space where we knew that social determinants of health were really the key drivers to health and clinical care was not going to solve or improve health outcomes alone. So, social needs really do go unidentified, and they go unmet. And part of the reason for that is there traditionally hasn’t been a an opportunity to meet individuals where they are and identify those social needs. And as a result, they go on to impact the the health outcomes of individuals. We also know that systems are fragmented across health care and also across community organizations. And what that really means is that what’s happening in the clinical space or what’s happening in health care may not necessarily make its way over to community organizations, or there may not be any formal or informal partnerships between the health care space and the community organizations to really facilitate high quality cost effective care across the continuum. And then lastly, we know that those referrals that exist to meet identified social needs, they lack visibility, so we don’t know who can see them. We don’t know who is necessarily taking ownership or accountability of meeting those social needs or or meeting those social needs through the services. And then we also know it’s difficult to track whether or not those needs were met through those those referrals and the services that are attached to them. So with that framing, we about five or six years ago here at the agency agency started to think about this new model for whole person care. And we didn’t do this unilaterally. I don’t think that we were the only state agency that was thinking about this new model for whole whole person care. And in fact, we found that a lot of these components that we thought about were also being, considered by other state agencies, whether that is Medicaid, health, human services, or otherwise. So I wanna just kind of walk through what these four key concepts are here on the left hand side of the slide and and what that means in the whole person care model as well as in the social determinants of health space. So the first is the integration of social needs into care delivery. So as I mentioned on on on the previous slide, health care alone is not enough, but there has to be an intentional integration of social needs being addressed in the health care system and in care delivery. And whether that exists in the outpatient setting, the inpatient setting, or in other spaces, we know it’s really important for that integration to be intentional. And next, we we think about the idea of connection. And the connection not only to resources once identified once needs are identified, but also the connection between those clinical and community ecosystems or community based organizations that can really help facilitate the meeting of those social needs. And then next, we have this idea of tracking. There are several, threads and points within my presentation today around data, but we we know that data is not the full picture. But in order for us to really see a return on investment, for us to understand the impact that we’re having, it’s important for us to be able to track those outcomes beyond the point of referral. So it is great to know that a referral was placed, but what happens after that referral is really important, especially in the immediate term. And then as we think long term and look at those health outcomes and the improvements of those health outcomes, we have to be able to track that in some way. And then lastly, this idea of building sustainable and scalable solutions is really important. We, at the agency, put a lot of emphasis on thinking about scalability and sustainability throughout all of our programs, especially here in the social terms of health space. And we we try to integrate that into the strategy as we’re building out our programs. Alright. So that leads us to our health starts initiative. So as I mentioned, we started thinking intentionally about whole person care, social determinants of health, health related social needs about five or six years ago when I started here at the agency, and we developed the Health Starts initiative as a result of some really intense strategic conversations. And it is our approach to whole person care. And what health starts is is our our, this idea that by focusing on the conditions where individuals live, work, and play, we can improve the health of of our member population. Ten care covers about one one point five million individuals. And so, when we think about the impact that addressing social determinants of health can have across our population, it’s it’s it’s really significant. And then when we think further about the the vulnerability that exists in the Medicaid population as we’re covering primarily, pregnant individuals and children, we know that it’s extremely important for us to be intentional in how we intervene or how we provide systems for intervention to exist in the health related social needs space. So the the depictions here below just really kind of further delineate how we we think about social terms of health and and that it really starts before illness, and it’s important for us to prevent and address needs early. And that prevention doesn’t necessarily just exist in the social determinants of health space. We also have a strong population health models that help support early intervention, and also support consistent early and periodic screenings, vaccinations, and other other efforts to support overall health and well-being across our member population. We also know that communities and and social ties are really important, and health really does begin there. And we think about, in our homes, having safe and stable housing, having electricity in housing, to make sure that refrigerators work, air conditionings air conditionings work, making sure that air filters work to ensure that that environment is extremely healthier, as healthy as can be for our members, but also in schools and understanding that individuals that schooling is individuals, do put it there’s an emphasis on education for all individuals and not just for children. We have a a significant portion of our population that desires to, improve their education, go back to receive more education, and that is a really strong indicator of of health and the ability to achieve optimal health outcomes. And lastly, in our jobs, we spend a lot of time working, and, it’s really important that we’re able to do that and to do that healthily and to be able to show up to work as our best selves. So with that in mind, we have our Health Starts vision, but then we also have our our vision or our Health Starts program and then our vision for whole person care and for Health Starts. So this this top tagline is really how we think overall about health related social needs and social determinants of health care at the agency. And it says that a health care ecosystem where health related social needs are not an afterthought, but a foundational element of whole person care. And what this means is that we want social determinants of health, health related social needs to be integrated into the fabric of of care models. And whether that is in the inpatient setting or outpatient setting or otherwise, we want it to be a part of the day to day tradition that exist in the clinical space, and we recognize that is a really significant, and lofty goal. But we’re hoping that through our strategy and some of our guidance that we can support providers and others to be able to do this work and to do it more continuously. On the left hand side of this slide, you’ll see, there is a a Venn diagram here that really depicts our existing population health and data ecosystem. And each of these bubbles, excuse me, each of these bubbles are attached to, different role players in our population health model. The first is our MCO model of care. So this essentially says, how is it that our managed care organizations are providing care and support to their member population? As I mentioned, there are robust population health models that exist across our managed care organizations, and there are significant insertion points for health related social needs within those models. We also have risk stratifications and other concepts that really support identifying opportunities to improve the health of individuals based on their current state and based on their their living, based on their circumstances. We also have provider care delivery, which is very similar to the MCO model of care in that it is based it it really means how how is it that providers are providing adequate care to our members. We have some providers who have been have integrated health related social needs practices and social care practices into their into their care models for many years prior to to to TennCare really diving into this space. We have others who are still kind of dipping their toe in the water and trying to understand how to integrate this meaningfully. We also have some providers that have integrated social supports, if you will, within their practices, such as food pantries or clothing closets. So there’s a wide spectrum of how providers provide care to our members, and that’s really what that particular portion is about. And then next, we have our CBO network. And this is not just community based organizations. It also includes our nontraditional health care providers like community health workers and doulas and lactation consultants and how they’re able to, insert themselves into the clinical model of care while also maintaining integrity in their role. And, for the CBO for the CBO piece, it is CBO’s ability to provide services such as food boxes and clothing and utility assistance to our members and how that is probably one of the most critical pieces to this puzzle and standing up a program, for health related social needs that is sustainable and scalable and also reflective of what our members need most. On the right hand side of the slide, this just talks a little bit about our work streams here in health starts. I’m gonna focus today on b, technology supports, but do wanna provide just a little bit of context in provider partnerships as well as workforce development. Provider partnerships is our program specifically related to addressing social needs in the provider setting. And the provider partnerships program is our most mature program, and we actually use a lot of the learnings from that program to fuel how we think about technology supports or our work with find help through Tennessee Community Compass. And workforce development is our approach to integrating nontraditional health care providers like community health workers, doulas, lactation consultants into care models. And the this is actually one of our newer programs and happy to talk more about either provider partnerships or workforce development offline or if we have time during questions and comments today. Alright. So this is my last vision slide, and then we’ll really get into into the meat of the presentation today. So this particular slide is our vision for Community Compass. And I should also say Community Compass has been a labor of love for us for many years. For those that are familiar with procurements, they are tough, and we we spend a lot of time, a lot of resources in in building out what we thought an ideals an ideal system and platform would be. And and Findhub has been an absolutely incredible partner in this journey with us as we’ve been, trying things and, not trying things, placing things into the model, and moving things out of the model. But, overall, our the structure and the purpose and the vision for Community Compass has remained the same even as we’ve learned along the way. So three primary buckets here as we think about community compass and and what we really want to accomplish and what we want it to be involved in the system. The first is that we wanted to be able to strengthen CBO relationships. As I mentioned on the previous slide, CBO relationships or the CBO network is a really critical piece to the to the puzzle of addressing health related social needs. Individuals can have needs identified, but if there is nowhere for an individual to go to get a referral to have those social needs met, then actually identifying those social needs doesn’t really do much other than providing a data point and and placing an individual in a space of vulnerability to disclose the fact they have needs, but then we’re not actually doing anything to achieve them. So within the CBO relationship space, we really wanted to support the work that CBOs do, recognize that they are not medical providers. We didn’t wanna overmedicalize the CBO space and encourage reliable referral pathways. We also wanted to ensure that programs are claimed and actively accepting referrals, especially in rural areas where there may not be a lot of referrals or a lot of, referral options for a particular individual. We recognize that not all CBOs are in a place to receive referrals, and that’s okay. But we we put a lot of emphasis on ensuring that we can build out that model as much as we can to build out that network as much as we can to support our members as they’re being referred to services. And then lastly, recruiting and incentivizing CBOs to join focused network. So we’ve done a lot of work with our managed care organizations, a lot of work with Find Help and the Rural Health Association, which I’ll talk a little bit more about later, to, recruit and incentivize CBOs to meet certain milestones in order to improve or enhance their engagement with the platform. We also, wanted to focus on a unified approach to addressing health related social needs. And what this really means is ensuring that there is loop closure from MCOs and, providers, state agencies, CBOs, or and even the member. And we also wanted to leverage the connectivity and the data congruency to provide streamlined care and support that consistent member experience. As I mentioned, it’s not always about the data point, but we all we wanna make sure that the members are actually getting the help that they that they need and also to ensure that there is a level of of transparency across that across that data flow. And then lastly, we wanted to measure the impact of addressing health related social needs. And and this is a place that we we spent a lot of time thinking, but we’re also very early on in our in our integration of Tennessee Community Compass. And so haven’t been able to look at some of those longer, or some of those outcomes that take a little bit longer to realize. But we did wanna start the process of collecting meaningful data and developing an integrated database to to store that data so that when we’re ready, we can pull that data out and begin to bump it up against some of our other data sources here at the agency. We also wanted to emphasize standardization and alignment in data elements that are being reported, and that’s really across our MCOs to make sure that we’re comparing apples to apples and oranges to oranges. If we’re continuously gathering different data points from all of our different partners, there we have we don’t have the ability to really track and and scale and to do that to do that intentionally and meaningfully. Alright. So here are the four kind of primary concepts within Tennessee Community Compass. So these are not unfamiliar to the social care space. We’ve just kind of thought about how do we adapt these to our particular population and ensure that it works with our strategy and what we’re trying to achieve in in the long term. So the first is a social needs assessment. Social needs assessments are embedded either in our managed care organization case management systems. They are also embedded within key provider partner EHRs. And and what that does is it really improves the the experience for our partners in ensuring that they have a streamlined, a streamlined way to address health related social needs. One thing that’s really unique about the model here at TennCare as we are kind of leading the way for for Tennessee in a statewide closed loop referral system is that we are social needs assessment agnostic. So, we are open to whatever screening tool a particular partner would like to use. We do have a a set set a set of domains that we are particularly interested in, which includes food, housing, transportation, and then navigation supports, which is an intricate category, but essentially says that there might be a particular organization or a a CBO specifically that can provide support to an individual to assist with, receiving housing, for instance. So maybe that’s helping with an application. So that’s not that doesn’t fit very clearly into one of those other three primary domains, but is one that’s really important and we found to be critical in this space. Next is the community resource directory. We wanted there to be a public facing directory, which we have, in in a public URL where individuals can, can navigate that re that resource directory on their own, but that resource directory is also integrated into those, it’s a part of the integrations for all of our our partners, and they can customize feature programs, favorite folders, and all of those things based on the community resource directory and their organization’s needs. We also wanted there to be, and there exists the referrals to community based organizations, which I think kind of goes without saying. We have many partners that are sending referrals to community based organizations. We also have instances in which individuals decline referrals, and that’s also okay. But we wanted that functionality to be there, and it is it is definitely being used in in our our current model here. And then lastly, the social needs outcomes and tracking. This might be the last time I say tracking in the presentation. It may not. I’m not sure. But it is something that’s really important for us here at the agency, and and this really is a critical point to ensuring that we are meaningfully integrating the system and and meeting folks where they are and meeting the needs of our partners, and we’re able to do that through through tracking data. Alright. So I’ve I’ve talked a little about the kind of care models that exist at the provider level and at the MCO level. And I wanna kinda just talk a little bit about kind of what was the previous state before we, went on this journey to find help with community compass and then kind of where we are now that we have a a statewide system. So before, there’s a lot of different approaches across managed organizations and providers and how they, one, screen for social needs and then also how they’re connecting individuals to resources. So, some providers just had a list of community based organizations on the fridge in the break room, and, they would just go to that list and say, here’s the food bank that we love. Let’s send let’s send our our patients there. In other instances, there are just community advocates and community experts that know exactly what resources are available, and they’re just pulling those out of the top of their head, sharing them with their with their patient or whoever’s in front of them at the time, and and then going from there. So no release no standardized approach, but there’s also the inability to really ensure that that information is accurate and up to date. If a community based organization changes their phone number, that that list on the fridge in the break room is not gonna change. And so we wanted to to try to provide a little bit of certainty in in the quality of the resources, but also ensure that there are adequate resources regardless of location and and across the state for individuals to place referrals. We also couldn’t scale across the ecosystem because we just had too many too many perspectives and too many approaches to really be able to have a refined approach as we move forward. And then TennCare at the time had no visibility into processes and data outcomes. We were solely just the receiver of information from our managed care organizations or from our providers, and we had had no say in kind of data points. We had a little bit of say with our managed care organizations, but generally speaking, not a ton of control over over that social care process. And so now we pretty much have the antithesis of that through through the platform, and and we’re really excited about how we’re able to to take the the continuity and the congruency that exists now and and use that to inform how we scale and how we strategize in the coming years. So this slide really just kind of depicts the entire social care workflow that exists across our partners. So there are some variances in each of these. For instance, obviously, I’ve mentioned our screening tool or the screening tool approach, and that looks different based on our partners. Some of them have longer screening tools. Some of them are a bit shorter. We have some that use prepare, some of them that do not, some of them that use homegrown tools. So it really just depends on the organization and what their needs are. And then there’s an opportunity to identify gaps or identify those needs through through those assessments. And then we match to the resources. They refer to resources, and then TennCare receives that data back for TennCare members only. One thing that I’ll also mention kind of in this workflow as we’re thinking about the provider setting specifically, providers can leverage this workflow across their patient population. It is insurance agnostic. Individuals can be commercially insured, Medicare, Medicaid, or uninsured, and they can leverage this exact same workflow. That was really important to us to ensure that providers were not experiencing a level of abrasion because they were trying to decide, well, this is a member, so I have to do this particular workflow. But when I move to another patient that does not have TennCare, then I have to come out of this workflow. And we recognize that an individual may not have TennCare today, but they may next month. And so if we’re able to meet their social needs while they’re not a TennCare member and they eventually become a TennCare member, then we’re already, when we enter into, into their life circumstance, we know that they’ve already had some social needs that have been identified and addressed and hopefully on a pathway to become healthier. One other key feature that I I wanna highlight that I think is extremely valuable, and I would also say is probably one of the the the features that we explain the most and sometimes get the least amount of understanding, and so we reexplain it. And so through that process, I’ve learned how to explain this probably five different ways to a lot of different groups. But this particular feature is called our coalition feature, and it is structured care coordination. We thought it was extremely important for us to think about how is it that we can ensure a few things. One, that if an individual is seen by multiple folks across the TennCare health care continuum, and they have leveraged or they they interacted with Tennessee Community Compass in one of those circumstances, how can we almost guarantee that wherever they present next knows that they have that interaction with Tennessee Community Compass. And and coalition consent or coalition allows us to do that. So the coalitions enable a secure, organized collaboration across entities that are leveraging Community Compass, and there’s proper data segmentation for the sake of security and privacy. And then that’s also based on our managed care organization membership. MCOs are all in their own coalition, and that allows for separation of workflows and for data. And as a result of that that separation across MCOs, we’re also able to ensure that if an individual falls off of TennCare coverage and then comes back on to TennCare coverage and then they move to a different MCO in that process, there’s no visibility that exists across the MCOs. There’s also permission based access. So only users are only able to view, refer, and report within their designated coalition. So they can’t jump from coalition to coalition. There’s also referral matching logic. So members are matched to the correct coalition based on their eligibility and the manage your organization assignment. And then lastly lastly, there’s some custom commit configuration. And this custom configuration also includes the ability for, individuals to, have their own consents for coalition as well so that exist on each of their white labels or may exist within their assessments. And and so that there’s a high level of customization across the board with coalitions. But at its core, we’re accomplishing the same, the same thing. So one example that I like to give to just add a little bit of color to how coalition plays out in practice is if we have one individual who, is with their MCO, in case management, and they are screened for social needs using Tennessee Community Compass. They opt in to coalition. They say, yes. I wanna be a part of coalition and share my data across the coalition. And then they receive a food box from their MCO or receive a referral for a food box from their MCO. And then let’s say the next month, they go over to one of our health care providers in West Tennessee, and they are West Tennessee is is using this particular using Tennessee Community Compass. They would be able to see that this member talked to their MCO a month ago. They received a food box as a referral or as an opportunity to meet a social need, and they can follow-up on that referral. They said, hey. I did you get your food box? Yes or no? Did you if you didn’t, can I give you a different referral to get another food box? And that’s really important because sometimes folks get lost in in the pathway, and referrals get lost in the pathway if there is no additional follow-up that happens afterwards. And we wanna make sure the individuals are getting the help that they need when they need it most. And so coalition consent allows us another opportunity, another intervention point, and an an informed intervention point that does not cause member abrasion by reasking the same questions. And and and that’s really important to us to ensure that we’re protecting the member throughout this this social care workflow. Alright. So this next concept of unifying the ecosystem, I’ve talked a little bit about of how a little bit how a little bit about how Tennessee Community Compass is being leveraged across our ecosystem, and we’ve engaged key partners across the care continuum. So a wide variety of folks that are leveraging Tennessee Community Compass. The first are providers. We have some value based payment providers such are such as our patient centered medical home population as well as our Tennessee HealthLink population, which is a behavioral health value based payment program here at the agency. And, a lot of those providers were already integrating this work into their care models, and so Tennessee Community Compass is is merely a complement to that workflow. And then we also have large integrated health systems. Some of those are leveraging it within their maternal health population. Others are leveraging it in their in their ED and and in their outpatient clinics. So there’s a wide variety of approaches based on the particular provider or health system that might be leveraging the the platform. We also have our three managed care organizations, which I’ve I’ve talked a good bit about today, and then we also have state agencies. And one of our state agencies right now is Tennessee Department of Health, and they’re leveraging the platform in three of their programs. One of which is a care coordination program. The other is viral viral hepatitis, and the other is evidence based home visiting. And it’s been really exciting to see how Tennessee Community Compass can exist in in kind of the nontraditional provider space through the health department. And we also know there’s a lot of overlap that exists between TennCare member and also health department presentation. And so we’re excited about the ability to to kind of look at that data and understand how we can serve our members better based on where they’re presenting across the state. So next, I think probably one of my favorite topics in in this work is community engagement and how we’re building a strong network to ensure that we are supporting members in in the referral and social, in the social services process. So, find help has partnered with the Tennessee Rural Health Association to support the community engagement work for Tennessee Community Compass, Tennessee Tennessee Rural Health Association has done a lot of work in the community and and definitely will be considered experts across the board in in how they have built relationships over the years to to meet CBOs where they are, to provide advocacy and resources to support organizations across the state, not just in in rural in rural places. So here are just some some key concepts that exist across the community engagement work stream of the larger Health Starts or the larger Tennessee Community Compass work. The first is the training and onboarding of CBOs. We recognize that not all community based organizations will want to leverage a technology platform, but for those that do, they need training and support to make sure they’re able to do that and to do it efficiently. There’s also the expanding of the resource directory and increasing the engagement across organizations. So what this means is that we wanna make sure that the organizations that are in there are the organizations that are in there are are ones that are able to meet the needs across our population, but we also want to increase that number if we can to make sure that there’s an adequate volume of organizations to meet to meet folks where they are. There’s also the supporting of participation statewide, so making sure that there’s representation across the state. Tennessee is a very wide state, and there is a very wide range of needs that exist. We have very rural areas. We have a very urban areas. And each of our regions of the state, we think about them in east in the east, middle, and west. Each of them have kind of their own personality, and and we wanna make sure that there are state there’s statewide support and representation across the state to not necessarily just meet those personality types, but making sure that the rural areas have enough resources. The urban areas also have enough resources. And and then lastly, we have ensuring that those accurate those programs are accurate and up to date and monitoring how active they’re being or how engaged they’re being in the platform so that if if RHA or Find Help needs to intervene to provide necessary support to those organizations, they can do that. Alright. So as we think about, this concept of data and how that that fuels and informs our decisions, the first concept that I wanna talk about is is just this idea of making social needs visible, and that really is, has been really important to us, and and Find Help has done a lot of work in providing really robust dashboards to support data visualization for us. So we have geographic insights through heat maps. We have, the ability to see member level insights as well. So we have PII dashboards. We have aggregate dashboards. We can, track how referrals are how many referrals have been sent out, how many screenings have been done, what those look like across all of our partners, many filters and stratifications across across the across our dashboards. And then the secs the the second is how we’re we’re driving better outcomes through this data. So we’re able to identify gaps in services, allocate those resources effectively, and then also being able to measure impact across populations as well as improving that care delivery over time. Improving care delivery over time is is one of the things that’s, as I mentioned, very significant, but also one of the things that takes a little bit more time. And so we’re continuously thinking about what data points and elements are important to us in order to inform that process and that future work. Alright. So some key insights that I wanted to share with the group here. These are really tied to what we some of these are are based on what we learned, as I mentioned, very early on through provider partnerships and how we use that to fuel the development of of community compass. And then others are things that we’ve learned as we’ve been in this work with find help over the last, few years and and things that we think is important to share with folks that might be interested in or in the early stages of embarking upon a similar a similar, pathway. So the first is intentionally designing a system to support our key partners. We prior to to jumping into this work with Five and Help had a very clear vision of who we wanted to to to be impacted by a statewide CLRS. We knew we wanted our management organizations. We knew that our value based payment providers were were also, very interested in in viable candidates to leverage the system. But we also wanted to make sure we’re being very intentional about receiving feedback from those partners along the way and and adjusting workflows, adjusting capabilities and functionalities to support them. The next is considering the community resource directory, a key facilitator of success. We heard this from several other states as we’re doing our our kind of landscape analysis. But in practice, we found that this was in extremely important. And and FindHub has done a lot of work in ensuring that all partners are able to submit the the community resource or the community organizations that they want embedded in the community resource directory. If those meet the standards and the qualifications and criteria set out by Find Help, then they add those programs. And that’s really important to us too because there are organizations that I’ve mentioned that have already been doing this work. We’re already leveraging some sort of informal community resource directory, and we’re comfortable with certain organizations and services. And so having that level of familiarity embedded into the platform is is really critical and improves the overall experience of the platform, and then that goes on to drive the data that we’re able to extract. So lastly, I wanna talk about scaling and and building for sustainability and kind of how we think about that here at the agency and through Tennessee Community Compass. So I’ve talked about how we we started off with this statewide infrastructure, procured our own contract that is owned by the Medicaid agency to stand up a statewide closed loop referral system. And then we’ve got this idea of cross sector collaboration and and being very intentional about the feedback that we receive from our partners being very collaborative across our partner organizations as well and making sure that we’re not not operating in a silo and that we’re also speaking to the things that are truly our area of expertise and not speaking to the things that are not our area of expertise. Our providers know what works for their for their population. They know what they need their staff to do, and sometimes they they just need the the infrastructure to do that. It is our job to provide the infrastructure, and to not overstep into into their area of expertise. And then, that kind of takes care of the continuous feedback and the improvement and making sure that we’re embedding, embedding the feedback timely so that they can start to see the changes and the differences in their experience as a result of the integration of that feedback. And then lastly, it’s the ability to scale across populations and regions. So, as I’ve mentioned, we’ve got several partners across, across the care continuum and across the state, and, each of them are thinking about scaling this across their their patient populations. Our MCOs are already scaling across their member populations and really are focused on how do they increase their touch points with members in order to integrate the social care workflow into their processes and to touch more members and ultimately improve health outcomes in that way. So what’s to come for us? So I I talked a lot about our vision, where we are today with Tennessee Community Compass, and we’ve we’ve got a lot more work to do. And we’re really excited that we’ve been afforded the opportunity to do that, especially through the rural health transformation program. And we’re actually gonna be expanding to three other state agencies. So I mentioned health is is leveraging it with three of their programs. They’re gonna scale it across their their state agency over time. We also have our department of human services as well as disability and aging that are gonna be leveraging Tennessee Community Compass through the Rural Health Transformation Program. And we’re incredibly excited not just for the data points, but for the opportunity for other state agencies to have an to have the option to integrate such a powerful workflow across their population and and then for us to be able to share data with each other and to inform our strategies as we continue to do this really meaningful work. Also, Tennessee Community Compass as a result of r h of RHT will be funded through twenty the end of twenty thirty one, and that is monumental for us in that we we recognize that that funding and, well, finances in general are a really tough space to live in, specifically with social care when there’s billable codes are not in play, and there doesn’t seem to be a consistent pathway for financial sustainability. And so we’re excited about being able to maximize our time up until twenty thirty one, but we’ll also continue to, to to ensure that we’re talking about the value of Tennessee Community Compass, talking about the impact that it’s had on our member population to continue this work well beyond twenty thirty one. Those agency implementations that I mentioned will occur simultaneously and simultaneously ish, if you will. So it really depends on where each agency is. They’re all in different places in their social care work, but we we plan to roll it out relatively simultaneously across those agencies. And then, also, each of them will have agency specific scopes to support that implementation, and we’re really excited about Craig Dalton joining that work. He’s been our state director. It’s been fantastic and has really been leading the statement of work development and also helping us think about strategy and governance across the board. So, with that, that is the end of my, my slides as they of me talking, essentially. But I wanted to pass it to kind of the to the attendees here and just get a a feel for who all we have in the virtual room with us and and kind of maybe inform some of our our questions as we move into that portion of the discussion today. So the the poll that is on the screen is where is your organization in charting for own social care road map? And there are five different options here. The first is exploring opportunities to implement social care workflows. So maybe you’re not quite there yet, but you’re really interested and wanna think more about how to do that. Then there’s also your screening for health related social needs. That’s the second option. The third is establishing partnerships or CBOs and or CBOs, and in doing that somewhere in the health care continuum that you work within or the health continuum that you work in. And then investing in technology to support workflows is the next option, and then building toward a closed loop referral system is the last. So we’ll give you all a few moments to tackle that poll. Yeah. Thanks, everyone. Thanks so much, Nicolette. Your presentation, and it was so great. It’s awesome to hear about the wonderful work that TennCare and your partners have been doing over the past couple of years. It’s been an honor, from my perspective to be a part of this work. We are seeing some of those, polls come in now, which is awesome. Please, take a moment, vote in that poll. I know it only gives you one option. So if you can just choose the the top one that you’re focused on, right now, that would be wonderful. Looks like building towards a closed loop referral system is winning with forty five percent right now. Alright. Thank you all so much for your responses here. We’re gonna go ahead and transition over into our q and a section. So if you haven’t already, please go ahead and add some questions into the q and a session section on the right hand of your screen there. Nicolette, we do have a few questions that have come in so far. The first one is what kinds of incentives are you giving CBOs, especially small ones? Absolutely. Good question. So there are financial incentives, unrestricted funds, which is we’ve learned very nontraditional, and and we support kind of leading the pathway of innovative opportunities to to support CBOs. It is milestone based, so it’s not just an upfront funding model. They are having to meet milestones along the way over the course of the year in order to receive those funds. They also are some of those milestones include training and keeping their information up to date, meeting certain referral benchmarks. And the we’ve actually just reworked our incentive model. So in this new model, there is kind of a control for large organization versus smaller organization, but there is there’s no size restriction on organizations that can be a part of the incentive model. Our managed care organizations help to inform which organizations will be included in that incentive model, and that is supported by data and engagement that exist in the the Community Compass platform. Awesome. Thanks, Nicolette. Any other questions that folks have? Please go ahead and drop those in our q and a. I see another one in here, but I think it was meant to be a response to our poll. Yeah. What questions do folks have about the the innovative work that Tencare has done? Okay. Well, I’m gonna go there’s, okay, couple that have come in now. There’s a question about timelines for disability and aging. Nicolette, do you wanna speak to that? I can speak to it the best that I can. I don’t have a timeline for disability and aging, mostly because we are still in the contracting process for the real World Health Transformation process. So we have several steps before we get there, before we’re able to really think about timelines and implementation. World Health Transformation has a very strict time line for, getting funds allocated, getting contracts signed, and so we’re we’re sticking to that very, very closely. So we’re hoping to start our work later this year, around September or October, and then implementation will will fall after that. Awesome. I’ll ask you a couple questions since, I know there’s there’s questions that we get frequently. What where do you see Tencare and your provider partners going in terms of integrations and innovations in technology moving forward? I think that’s something that comes up really frequently in the work that you and I do day to day. Where what successes have you seen with some of our our partners, and and where do you wanna see those those partners go in the future? Yeah. That’s a really good question. You know, there, the integration piece of this work has been really critical for a lot of organizations. I think more critical than I than I anticipated. We have some organizations that start this work, and they’re like, we want the Cadillac version of integrations. We want all the things. And it it is really exciting to see that they’re willing to kind of take on the lift of technology to support social care. And I think it really speaks to the investment that they’re willing to make into social care and how critical they they find the space to be, which is kind of a flip from from where we were ten to fifteen years ago in the health care space where clinical providers were saying, this is my lane, and I’m staying in it. It had nothing to do with social care. So as we continue to look forward and think about rolling this this platform out to other organizations, I hope that we can continue to see EHRs that are that are willing to integrate, to find help to support a variety of different providers in in their integration of of Findhelp in their their care models. And then I also hope to see that there are opportunities for organizations to really leverage the data that exist in those integrations and in those platforms to drive their own in their own quality improvement at the clinical level. So we use a lot of that data on a on a member population level, but I think there’s real opportunity for for providers to leverage the platform to drive some of their data and to improve how they provide care to their members across the board. Absolutely. Such a good point. The the data is something that comes up all the time for us, and I think, working continuously towards how can we leverage that data to show the great work that we know is happening, with our partners, across the state. Another question for you, Nicolette. What challenges or hesitations did, senior leadership express when building this up? How how do you get everybody onboard the ship to to get this officially launched when you first started? Yeah. Good question. You know, I’m I’m really fortunate to work at an agency where leadership is extremely supportive. I I think in some ways, our our chief medical officer was more excited about it than I was some days and and and really is an advocate for us across our executive executive leadership team at the governor’s office during during legislative sessions. And and and so not a ton of pushback from that perspective of why do we need the platform that doesn’t feel like a good investment. One thing that we we had a a point of contention for us in any sort of technology platform, but especially this one because it was so new, is getting CMS to understand the platform and understand what it actually does and how it is used across across the health care landscape. So we have great teams here at Tencare and resources at Tencare that helped us to kind of sell that particular portion of it. The other piece, I would say, is from a security and privacy standpoint, we’ve had a lot of conversations with our internal teams around that, and making sure that the system is secure and making sure that it is meeting all of the very specific benchmarks for TennCare as a Medicaid agency. And so not necessarily a a man an insurmountable challenge, but one that we’ve spent a lot of time on, especially during the development of our request for proposal and then once we got into implementation and started to see these things in practice. One thing I would say as far as challenges related at the at the legislative level, we put a lot of emphasis on on member stories and and really telling how members have been impacted or providers have been impacted by the initiatives that we’ve done through Health Starts, and that includes Tennessee Community Compass. And so we’ve put together some really, really strong member stories, and we look to our partners to help provide those to us. And I think that helps with mitigating some of the the uncertainty around, like, does this actually work, and does this actually make sense? And and once again, another plug for our amazing chief medical officer who does a great job of telling those stories in in front of the right folks and ensuring that we continue to receive funding and receive support to continue to continue this work. Awesome. Couple of other questions, before we close out for today that have come through the chat. Can you talk through the incentive milestones that you mentioned for referrals a little bit deeper? Sure. So the intensive milestones, I don’t have them up in front of me right now, and, also, we haven’t quite got to full finalization. So I don’t wanna fully disclose the the next incentive model because it’s not final yet. But an example of the referral milestone specifically would be if an organization a community based organization has received a referral, did they respond to that referral in a reasonable amount of time, and did they do that at a reasonable proportion of the time? So let’s say that reasonable amount of time is five days, and then the proportion is that they’re doing that eighty percent of the time. And then another milestone would be on the closed loop side. If an organization receives a ref a referral, are they closing the loop on that referral? And what is that closed loop rate? Is that eighty percent or ninety percent? And so if they’re able to meet that milestone quarter over quarter, then they receive the payment. It is quarterly based payments, though. So they can meet a milestone one quarter and not meet it the next quarter. It is not an all or nothing incentive model. So we we know that organizations can sometimes be in flux, especially recently where there was a lot of shifts in funding for community based organizations. We wanna make sure they had many opportunities to meet milestones and meet milestones throughout the year as well. Another example of a milestone is loading their organization into the resource directory and turning referrals on. That is a milestone, and they can receive payment for that. So not all of them are database. Some of them are purely just action based. Did you do this thing? Yes or no? Really to set them up for success throughout the rest of the quarters. Hope that helps. Absolutely. Yeah. I think there’s different stages of this. Right? And we what Tencare has done a great job of recognizing is that every org is really at a different level of this, and there’s different levels that might be appropriate based on the type of organization, their size, what they have available for volunteers versus employees. So I think it’s been, great to watch how, that flexibility has really allowed for increased participation of CBOs. Okay. I think we have time for one final question that came through the chat here. I’m gonna modify it a little bit just because I think that there’s, some it’s it’s a good question, but I I kinda have it for a little bit more broad than was asked in the chat here. So, what implementation barriers do you expect as you continue to expand and roll out to other agencies like the health department? And then what are you most excited about with the expansion and rollout that we’re planning through twenty thirty one? Yeah. Good question. So the good news is TennCare does have to own that implementation that implementation plan for those other state agencies, which we are grateful for because it is a a tough undertaking, but we are definitely gonna be great partners to our other state agencies as they are embarking upon this journey. As far as challenges, you know, the health department is is expansive, and there’s a lot of different programs. There are a lot of opportunities for them to insert this sort of work into their their model as as it exists today. And I think whenever you’re looking at a larger organization, the change management piece is probably the biggest, in understanding that there are well integrated processes that exist for these teams and across these departments and and asking them to kind of uproot those in some ways or to switch some components out to be able to support the integration of Tennessee Community Compass or any sort of technology platform is a is a really significant challenge. So I I think that’s the case really across all the state agencies. Change management is is is a really big one. I think the other thing is is really figuring out for each state agency, and I think this goes for anyone who’s standing up a closed referral system or even thinking about kind of a social terms of health strategy, understanding what the actual outcomes are that they’re looking to assess and being able to back out of that and determine what data points they need to receive and then take another step back and say, how is it that we get there? And and that’s something that takes a lot of time. It is an iterative process. And sometimes there are moments where you think that one data point is the right one, and then you find that there are significant gaps in that. So for any sort of any state agency in their implementation process, making sure that they’re really intentional about intentional about and bring the right resources to the table to think about those really critical those really critical questions that set them up for success in the long term. Wonderful. Thank you so much, Nicolette. Great responses. Great discussion today. With that, I’m gonna go ahead and close this out for today. Before you go, please, we we would really appreciate you taking our survey on how helpful this session has been for you all. Really, really appreciate your participation and attending today. Hope you have a good rest of your afternoon or evening wherever you’re at, and thanks again.

CONNECT SUMMIT 2026

Discover how TennCare is transforming member outcomes through the Tennessee Community Compass (TNCC), a statewide movement toward equitable, holistic care. See how they integrate SDoH into clinical care, unify the state’s social care ecosystem, and drive health outcomes.

Dallas College

Improving student persistence by 70% with Findhelp Fulfillment

As the Dean of Basic Needs & Student Care, Stephanie is proving to the higher education sector that student success depends heavily on meeting basic needs.

Dallas College has built a nationally recognized, data-driven social care model. Instead of just handing students a list of phone numbers, Stephanie uses Findhelp Fulfillment to provide immediate, tangible aid.

Stephanie Harris of Dallas College is a Findhelp 2026 Community Contribution Award winner!

“It’s inspiring to see the level of care Dallas College shows its students. It goes beyond the classroom—there is a genuine focus on holistic wellbeing. Their recent Findhelp case study is proof that all those hours of hard work and determination are paying off for their students. I feel so proud just to be a part of it. Huge congratulations to Stephanie and everyone on the Dallas College team!”

Taylor Olson

Customer Success Manager, Findhelp

Today, Dallas College seamlessly connects students to thousands of essential programs—even providing instant Uber Health rides and emergency gift cards to bridge critical gaps. Her innovative approach is directly driving student retention and rewriting the playbook for workforce development.

Good afternoon. Welcome to our session this afternoon, From Crisis to campus response, and statewide housing infrastructure in action. Join the Nebraska Investment Finance Authority, NIFA, and Dallas College to explore how integrated technology and housing policy creates stability for both statewide populations and students in crisis. I’m Lisa Boyle, senior customer success manager here at Findhelp. Before we start, a few housekeeping items. This session is being recorded. You will get access to the recordings, on Friday, May fifteenth. And please use the q and a tab on the right side of your screen, and we’ll do our best to answer questions at the end of the presentations. We have two presentations today, a set of paired perspectives. First, we will hear today from Nebraska Investment Finance Authority where they’re gonna talk about connecting housing and services using Nebraska dot find help dot com. Our presenter is going to be John Turner, community collaboration manager at NIFA. We will also hear how Dallas College meets students’ immediate needs. Our presenter for that session is Wednesday Newell, senior student care coordinator at Dallas College. Remember at the end of our presentations, we will take questions and answers from the, q and a tab. Alright. We’re gonna start today’s presentation with Wednesday Newell at Dallas College. Good afternoon, everyone. Before I introduce Dallas College or our model, I want to start with the end first. I want to start with the real student experience that captures why campus response matters. I supported a twenty one year old student. Do you remember being twenty one? This student was with it, bright, efficient, and actively responsive. If she said she was going to do something, she would do it. The student was enrolled full time, taking classes, passing classes, and she was also working full time. The job was emotionally and physically demanding. While working and going to school, the student was also serving as a caregiver for her two younger siblings, one in middle school and one in high school. She was waking them up, getting them to school, and providing them meals. The student also served as a caregiver for her mother who struggled with mobility challenges. The family had been living in a weekly hotel for a year and despite the student having steady employment, the cost structure made saving to move to an apartment nearly impossible. The price crisis point came when the student could not pay the next week’s hotel cost. Instead of focusing only on immediate relief, we partnered with the student to build a short term stabilization plan with the clear path to longer term housing. Using Find Help, we were able to coordinate resources in a paid housing support service to help the student move from weekly hotel living into a three week extended stay, creating space to save for a deposit and transition into a two bedroom apartment that the student could afford. That story frames today’s focus, campus response and action, How Coordinated Care plus the Right Tools Can Move Students from Crisis to Stability and Protect Academic Continuity. Now here’s what you’ll take from this session. One, how help supports rapid response and follow-up for students facing housing financial insecurity. Two, how addressing basic need barriers support academic continuity and retention. And finally, how find help strengthens rather than replaces relationship driven case management. Now with that context, let me introduce who we are and why this work is essential at Dallas College. So good afternoon again. My name is Wednesday Null and I am one of seven senior student care coordinators at Dallas College. I have the honor and responsibility of serving students through vulnerable times in their lives and helping keep the campus safe through chairing the care team. I am a licensed master social worker, and I have been a social worker for a very long time. What I enjoy most about being a social worker is empowering people with correct information so they can make the best decisions for themselves. One of the reasons I am proud to serve Dallas College is because Dallas College is rich in resources and people. Dallas College is a community college and serves a large and diverse student population of over a hundred twenty thousand students annually. Fifty percent of the student population is female, seventy seven percent are part time, and nearly one third are adult learners balancing school, work, and family. The college consolidated seven independently accredited institutions into one college model to remove structural obstacles that previously hindered student completion. Now Dallas College vision aims to break through traditional barriers becoming a twenty second century global institution where learners can pursue transformative learning opportunities anytime, anywhere. Dallas College provides several ways to take classes in person, online, hybrid classes, weekend classes, six AM classes, even eight PM classes. Now even though we have a variety of classes, we do not have on campus housing, which means students experiencing housing instability are navigating it in the community while trying to remain enrolled. Our mission is to transform lives and communities through higher education. This is another reason why I’m proud to serve with Dallas College. I get the opportunity to transform lives every day. I don’t have to do it, but I get to do it. And student care coordination, my department, is one of the ways we operationalize that mission with student when students face barriers outside the classroom. We are barrier busters. So that mission shows up in how we define student success in the pillars that guide our work. We have four pillars of success. These pillars reflect the Dallas College priorities that students care aligns with every day. Pillar one, student success. We strive to create a seamless supportive experience for students to succeed from enrollment through graduation and career placement. Pillar two, exceptional workplace. We strive to create an environment of continuous improvement where employees thrive, grow professionally, and deliver outstanding service to students, internal and external stakeholders. Pillar three, we prepare students for workforce readiness and economic mobility with in demand skills that local employers need, increasing economic opportunity across the region. We break down barriers to success and create pathways to higher paying careers for all community members. And pillar four, inclusive excellence and smart resource use. We build a community where varied perspectives drive innovation, continuous improvement, and everyone has an equal opportunity to succeed. We maximize our facilities, technology, and programs to best serve students and our community. The work we do is embedded in these four pillars. So you may ask, why does student care matter so much in a community college environment? College is more than classes. It is socialization, clubs, groups, organization, friends, and parties. It is learning how to manage your time and prioritizing. It is the first taste of freedom in making your own decisions. We found that college outcomes are influenced by life circumstances, especially for students balancing work, caregiving, and financial responsibilities. Students face real life challenges, the same challenges that you and I face, basic needs like food, clothing, shelter, utilities, and transportation. Let’s not forget that gas. These basic needs can quickly disrupt attendance, grades, and enrollment. One must understand that basic needs must be met in order to learn. Have you ever tried to do something when you are hungry? I have, and all I could think about is eating. What I’m going to eat, how it’s going to taste. So imagine if you did not have resources to obtain the food. That is a barrier. The student care work is about reducing nonacademic barriers so students can remain engaged long enough to reach their academic goal to obtain a degree or certificate. Now let’s talk briefly about the landscape of need we’re responding to. This is Dallas College student financial wellness survey results for fall twenty twenty five. It was conducted by Trellis Strategies, which is a research and technical assistance firm that focuses on the student experience. As you see here, forty percent of students reported housing insecurity. So students do not know where they will live either today or tomorrow next month or how they will pay for it. Forty four percent of students were found food insecure. Seventeen percent identified as parents. Thirty eight percent of students indicated a generalized anxiety disorder. Now the third reason right here is why I love serving at Dallas College is this eighty six percent of students. Eighty six percent of students say a college degree will provide them with a higher quality of life. That, ladies and gentlemen, is hope. Now when those barriers of food and shelter and mental health show up, here’s how our campus response is structured. At Dallas College, our response includes both the care team and the student care network. These roles complement each other. Dallas College has a care team because Dallas College cares about their students. That’s right. We care about the students’ academic, emotional, and physical success. The CARE team, which stands for Campus Assessment, Response, and Evaluation, was created to accept referrals regarding individuals in distress or whose behavior raises concerns about their well-being or that of others. The team consists of a group of qualified, dedicated college professionals with a shared focus on coordinated response when students are in distress or crisis with attention to safety, care, connection, and support. These dedicated professionals function in the role as police, conduct, counselors, nurses, student care coordinators, accessibility advisors, financial aid, and of course faculty. Now the Student Care Network is a holistic network of care that provides relationship based one on one support for food, medical resources, housing and rental assistance, scholarship information, transportation, mental health support, and academic navigation. We are the first point of contact for student resources. We are coordinating care and walking alongside students through the stabilization process. So, how do students actually connect with us? Well, they submit a referral. Students, faculty, staff, or community may submit a referral. They submit a student care referral online. We also receive early alerts, concerns, or walk ins. So once a referral comes in, here’s what the case flow looks like. Well, we receive a referral. The students behaviors are assessed. We reach out to the students via email or phone or both within twenty four to forty eight hours. Through email, we provide the needs assessment and the link to schedule an appointment. The student and care coordinator have an intake appointment. And during the appointment students’ needs are connected to resources through Find Help. The student and care coordinator create an action plan. The care team reviews behaviors. And then we follow-up. Now that you’ve seen the structure let’s remember our student. Now remember our remarkable student our wonderful student our selfless student who’s very with it going to school working and caring for family members Now that story I shared is not just one student. It reflects the complexity many of our students carry. When those demands of school and work collide with the housing or financial disruption the risk of stop out increases quickly. The crisis. So our remarkable, wonderful, selfless student experienced the crisis. Hotel rent was due, no savings, no plan. So what the crisis often looks like in student care is imminent loss of housing, inability to meet immediate cost, no food, and limited options. In these moments, the student isn’t choosing between school and success. The student is choosing between school and survival. Our goal is not only to resolve the immediate crisis but to create a pathway forward. The plan The student care coordinator and the student created a plan together. The plan was to reduce the immediate cost burden long enough for the student to redirect funds towards a deposit and longer term stability. The coordinator was able to access FindHelp website and services during the student’s appointment. We completed the application for Dallas College Emergency Housing, which consists of an extended stay hotel for three weeks. Hotel stays are usually strategic with a documented plan that leads towards stable housing and not as an open ended solution. The student had certain goals she had to complete. She had to muster up the courage to leave her extended stay hotel that she had been living in for a year. She had to pack and move. She had to save money. And for and finally, she had to find an apartment. But never fear. Her trustee coordinator had the technology and services to assist her. So through find help, the student was awarded the hotel stay and provided a housing coordinator that assisted with placement. The student was also connected with resources for food and shelter. So that’s where becomes a strategic partner in our workflow. Now we use FindHelp as an integrated support tool, not just as a directory or search engine, but a platform that enables coordination, documentation, and fulfillment of services. We use Find Help to identify resources, coordinate paid services like housing coordination, Uber Rise, to and from school or health visits, and financial support through gift cards. We also can track if the student accessed services and tracked follow-up. We are notified when the student actually got help from Find Help to Got Help. So Find Help supports tangible resources, tangible help. If you are hungry, you receive a gift card for food. If you need a ride to the doctor, we order you a ride to the doctor. While our team provides relational, Find Help powers our relationship. With Find Help, Dallas College moved from a referral based model to a fulfillment based model based one. Find Help fulfillment allows the college to order social goods and services directly from the platform ensuring students receive immediate support. The implementation removed the hurdles of contracting with multiple vendors which would have been too cumbersome for the institution to handle on its own. Now in addition to the powerhouse Find Help, there was still some work for the coordinator and the remarkable, wonderful student to do. There was six hours of direct work contributed. The student received housing placement coordinator. Support was provided during the transition, and we had to search for apartments. We had to search for stable housing. So I have some good news for you. Stability was achieved. The family left the weekly hotel, lived in extended stay for three weeks, saved enough money, and moved into an affordable two bedroom apartment. So the student exited from unstable temporary housing, had a successful transition period, and entry into stable housing aligned with income. This isn’t only a human outcome. It shows up in retention and persistence. So why does this matter? Why does retention and success matter? Stable housing leads to reduced disruption caused improved attendance and engagement which equals improved persistence and retention. Persistence means re enrolling from term to term and retention means re enrolling from year to year. So we’re investing in basic needs support because it protects academic continuity and completion. The return on investment. This is our return on investment from the marketplace services from fall twenty twenty three to spring twenty twenty six here are totals for students who receive find help marketplace services Total hotel placements, thirty five. Total gift cards, one thousand seven hundred thirty four. And total transportation supports, seven hundred for a total of two thousand four hundred and sixty nine students receiving Find Help Marketplace services. Please note a relatively small intervention like a ride to the doctor at the right moment can preserve an entire semester of enrollment. This chart shows the retention and persistence of students who received help through Find Help services. One of our strongest outcomes, the persistence rate from fall twenty four to spring twenty five was a ninety percent rating and from fall twenty four to fall twenty five there was eighty five percent, students re enrolled or graduated. So we see when basic needs are stabilized students are more likely to remain enrolled and maintain momentum. Now why does Dallas College choose FindHelp? It functions as both a resource pathway and a service delivery support especially through paid services that address immediate barriers. Also the platform enhances our response. It doesn’t replace human care coordination. It enhances it. Now Findhelp is innovation at its finest. It has been our experience. There are no other platforms that offers marketplace items. So before Find Help fulfillment, students were referred to community organizations and expected to follow-up. Now Dallas College can fulfill needs instantly. What I’d like for you to take away, I want you to know that crisis is common, but it’s addressable with care and technology. Basic needs is academic success work, and tools like find help strengthen consistency, speed, and follow through. When we reduce barriers, students can focus on the work they came to do, learn, graduate, and move forward. In summary, our case study, Dallas College, one of the largest community colleges in Texas, partnered with to support their comprehensive student care network that addresses students basic social needs beyond academics. By leveraging find help fulfillment, Dallas College can meet student needs immediately through services, such as emergency housing, ride sharing, and gift cards for food and gas. The initiative have led to to significant improvement in student persistence and completion rates. Now if you like to talk workflows, implementation, cost campus coordination, I’m happy to connect with you after this session. I would also like to thank you for your time, for meeting with me, and introduce you to my co presenter, John Turner. Thank you so much. Thank you very much, Wednesday. The the successes that you’ve had with Dallas College are very impressive. Really enjoyed hearing about that. You’d spoke about the case study. For anyone who’s interested, I’ve posted a link to that case study in the chat, so please check that. And if you have any questions, put them in the q and a, and we will now move along to John Turner. Thank you, Wednesday. Thank you, Wednesday. Hello. Yeah. Thank you, Wednesday. Thank you, Lisa. Hello. My name is John Scherner, and I’m the community collaboration manager at the Nebraska Investment Finance Authority. And today, we’re gonna talk about connecting housing and services. So every state in the union has a housing finance agency, and and we are Nebraska’s. We are a quasi governmental organization, and we were created in nineteen eighty three. I always like to start any kind of presentation with our mission, which is growing Nebraska communities through affordable housing and agribusiness. And there, you can see our vision and our values that we strive to achieve in any work that we do here at NYFA. So NYFA provides a lot of housing resources across Nebraska. And many of you may be familiar with your housing finance agency because many of them provide assistance for first time homebuyers and down payment assistance. So for homeownership, NIFA has provided assistance for over a hundred and four thousand homeowners across Nebraska since we began in nineteen eighty three. We also administer the low income housing tax credits, which really drive affordable housing production, and we’ll talk about that as I move forward with this presentation. And then community development, we’re very involved throughout Nebraska to try to help strengthen Nebraska communities, and and we do work with whole communities. We provide a level of technical assistance. And like my job title says, we do a lot of collaboration with communities to help them succeed. So today, we’re really focused on Nebraska dot findhelp dot com. That’s the website that we partnered with housing with Find Help to create. And really, what the focus of that is is is the connecting housing and services. It was partnering NIFA with Find Help to really create a unique relationship, I think unique across the country, to connect the properties that we invest in and that we help fund so they can provide low income housing, connect those properties with services. And why does this partnership matter in Nebraska is really what I’d like to touch on. So I actually looked this up before the presentation. The first emails we got from FindHelp were in November of twenty one. So we have been talking about this for a long time. The early conversations were really about what unmet needs there were in rental housing navigation. As I mentioned, we the Low Income Housing Tax Credit program that we administer that helps produce housing, gets housing multifamily rental housing built across the state, and I’ll show a map later that’ll show those. But we had those units, and we didn’t always have the best way to identify, like, these neighborhoods and people understand where these units are. You know, maybe if you lived in the community, you were aware of it, but we really wanted to have that footprint so people could find those. We needed a way to show what accessible features there were with those units and what kind of local resources there are. We also recognize that property managers need better tools. I’m a social worker. I started doing home visits. I did thousands of home visits across Nebraska, you know, when I was working with families and households and people with behavioral health issues. But property managers aren’t social workers. I mean, maybe you might have a few that might have wear both hats, but a lot of times, the property managers look to the community based services. And we just wanted to make sure that they had better tools. And that’s what’s so great about this summit is because we’re hearing so many great examples of those community based organizations. So we decided to partner with FindHelp to bridge housing and services and to launch nebraska dot findhelp dot com as a housing inclusive platform. So what you know, why again, why is this? The problem was a fragmented system leaves renters unsupported and property managers overburdened, harming stability and increasing eviction risk. The solution is to have a unified statewide platform that streams lie streamlines access to affordable housing accessibility options and community resources. So I mentioned the Low Income Housing Tax Credit program. This is just a snapshot of where those properties are across the state of Nebraska. We currently have four hundred and seven active projects. Actually, this is from twenty twenty five, so we probably have some new ones since then. But we’re looking at about fifteen thousand active units. And this is a a snapshot from another slide where we do kind of an NIFA one zero one for, you know, legislatures and different folks throughout the community. And it shows you what the income level is for four person household through the Low Income Housing Tax Credit units. So those rents are capped in those they’re they’re built, so you have to be below those income thresholds. So it really does work with people that are low, very low, and extremely low income. And one thing that’s great to see so we started talking to FindHelp in twenty one. About twenty twenty three is really when we got started with Nebraska dot FindHelp dot com. And it’s exciting for me to see this heat map of of the utilization and the search activity across Nebraska. It’s nice to see representation. And some of those kind of blank spots are very rural and don’t have a lot of communities in them. So this really is is pretty close to the LITECH map that I showed you earlier. So I mentioned that searches are getting stronger and stronger at NYFA, and so we wanted to do a poll and ask you. So the four things that were the top or the yeah. The top four searches in Nebraska with this Nebraska dot findout dot com are health, housing, money, and food. And I think we’d like to ask you if you could chime in and and which one do you think is the most searched. So you should be able to see that screen come up. Should be able to click on which one you think is the most searched in Nebraska. And, Lisa, I’m not seeing, results yet. Hi, John. I thought I’d join you. I don’t I’m making sure that I am adding it correctly. Well. We’ll move on. We’ll see if if I can get capture the answers on the back end. They may be captured on the back end. Okay. Sounds good. I just need to advance to the next slide if I can. Let’s see. I’m not seeing the advanced slide, but here we go. Got it. Okay. So big surprise. You probably figured it out. Housing is the most searched resource at sixty three percent. So you can see that that pie chart there that really shows the need. I mean, it I think a lot of folks probably on this call right now recognize that housing is a huge issue. Trying to find affordable housing, attainable housing is really tricky right now. You have to be creative. You have to build partnerships and really strengthen relationships with property managers, landlords. So but, you know, for me, the fact that this program exists and that more and more people are searching, it’s it just show it shows the need, but it also shows that we’ve built a system that is working and people are hopefully getting connected to the right place. So Nebraska dot findhelp dot com. It’s a free online resource to search for thousands of services by ZIP code. Every everybody on here is probably very familiar. This is a specific Nebraska site. When I do presentations, I have to kind of tell people, don’t type in findhelp dot org. Type in nebraska. Findhelp dot com because this is a unique thing that has housing listed. So we list those Low Income Housing Tax Credit rental units as programs on the site. And the one of the great things about the low income housing tax credit units is they have to take section eight vouchers or housing choice vouchers, which are sometimes hard for communities to find landlords that’ll take them. Well, these projects do take those section a vouchers. And a lot of people can’t live affordably without some level of rental subsidy, and they’re trying. You know? Even folks that are working still can qualify for a section a voucher, and they can use it at these projects. In Nebraska, we’ve spent a lot of time over the last year learning more and more about accessible housing. And so one of the things I like about when we list a unit, we can list one of the tags, the disability tags. So we can click that this unit is for a person with limited mobility. This unit is for someone with hearing or vision impairments. And so that’s really helping our community that has people with disabilities to at least be able to search for housing and then can see if it actually is accessible for them. So last year, fifty eight thousand nine hundred and seventeen total searches. And I like I said, sixty three percent of them housing related and help pay for housing, help find housing. And I would I would guess that that’s something happening across the country. So we have over four hundred properties on on find help. We also when you click help find housing, we also try to have some resources in there, like places that maybe have rental assistance. We in Nebraska, we have something called RentWise, which is a tenant education program, and you can take that online. And landlords will give people a second chance if they know they have a RentWise certificate. Some housing authorities will give that a preference on the waiting list so you can kinda move up the waiting list if you show you’ve completed RentWise. And like I said, the the properties are restricted to sixty percent area median income, which makes those rents affordable. I already kinda spoiled this, but take section eight vouchers and the units. If you get federal funding when you’re building housing, low income housing, you have to make sure that five percent of them are for people with limited mobility, two percent are for people with sensory impairments, hearing and vision. They’re scattered across Nebraska. And by getting the funding, NIFA, where I work, we have a compliance team that will do reviews, and they’ll do on-site inspections. So NIFA does collaborate with multiple groups and partnerships. NIFA brought me on eight years ago as a social worker, which is a little bit different for a housing finance agency. And since I did direct care, we really work to integrate with the reentry initiatives and the Olmstead planning, which is Olmstead, you know, for people that live in the lowest level of care possible, people with disabilities, the continuance of care, you know, to prevent and end homelessness, children and family collaboratives. And we’ve really been pushing this with the state legislatures this year because accessible housing actually came up. There was a bill to discuss and and and talk about accessible housing. We work very closely with in Nebraska, we have the Health and Human Services, and there’s several divisions, Medicaid, behavioral health, public health. So we work with those different divisions. And then we have a strategic housing council that’s goal is to produce more housing across Nebraska because we have a shortage. And there are four pillar groups in that council, and I chair the third pillar group was which is targeted to help households that make below twenty two thousand a year and what we call in the development world special need populations, which are covered in some of these groups we work with. So we do a bunch of training. You know, I I work really closely with the team at NIFA to make sure they’re very well versed and and find help. And we train the low income housing tax credit property managers at our conference every year. We have a big conference. That’s a picture of it. We just had that in April. And then we train the state economic development housing staff. There’s Nebraska. There are regional behavioral health authorities across the state. So we work to train those housing coordinators because they have some housing money, and I mentioned the health and union services. So the future vision is, you know, we have it set up now that when someone gets funding from us to build, as soon as that project is built and it’s ready to come online and start putting tenants in it, they go to our website. They fill out a form, and then we, NIFA, will add that unit, that property to the website. So the number of units is just gonna continue to increase. And we’re going to expand tagging. So any property that’s currently on there, we’re gonna survey them and find out, do they have accessible housing for people with limited mobilities and sensory impairments? So then we’ll add those tags. So eventually, you’ll start to see more and more accessible units on there, which folks with disabilities have been very vocal saying that it’s very challenging to find accessible housing. So we wanna try to solve for that. Collaboration, that’s what it’s all about. Deep in those partnerships, I’m working really closely with the property managers. I’m excited about Keep, and I saw that that was one of the groups you could join today. But I think keep is a great option for a property manager that owns multiple properties to keep track of the tenants that come in and ask for help. I really didn’t talk about that, but that’s what we want. A tenant walks into the front office and says, I don’t know how I’m gonna eat tonight. The property manager gets on find help and looks at where the nearest food pantry is and tries to get them connected. And that’s that’s starting to happen more and more, but I think Keap would be a great resource. So that’s something I’m excited about. And so all of this is about keeping tenants stable, stably housed. It’s about reducing turnover. Landlords want that. They want tenants to pay the rent and stay in the unit, and we wanna get people successfully placed in the unit that of their choice because it’s really all about housing choice across Nebraska. Alright. I got through it a little faster than I thought. So I guess we’ll see if there’s any questions. Alright. You, Ron. Thank you. This is the last call for questions for either of our speakers. You can put that in the q and a if you have a question. While we do that, we’re going to also publish a survey. If everyone who attended could just look in the survey section on the right hand of your screen and, let us know how helpful and interesting today’s session was. John and Wednesday, I really wanna thank you both for your time today, your information, sharing with us your successes, and the impact that you’ve had on your communities. Really, really appreciate it. I do not see any questions in the in the questions, so we will end here today. Thank you everyone for your time for being here, and have a wonderful afternoon. Thank you. Thanks, everyone. Thank you. That was enough time.

CONNECT SUMMIT 2026

Learn how Dallas College uses human-centered case management and Findhelp to deploy rapid-response interventions—such as temporary housing and transportation—that protect academic persistence and student well-being.

Thank you to our awardees

To Kimberly, Nicolette, and Stephanie: thank you for your vision, your collaboration, and your relentless commitment to making care more accessible. You don’t just use our platform—you bring it to life. We couldn’t think of anyone more worthy of the 2026 Community Contribution Award.

Across West Virginia, healthcare providers, community organizations, state leaders, and advocates are working toward a shared goal: building a more connected, person-centered system of care. At the West Virginia Social Care Summit, speakers explored how Medicaid transformation, integrated technology, cross-sector collaboration, and community partnerships can increase connection and improve outcomes for people across the state.

Read on for key takeaways:

Integrated infrastructure is essential to whole person care. Speakers emphasized that successful social care transformation requires coordinated technology, shared workflows, strong partnerships, and sustainable investment.

Relationships remain at the center of care coordination. While data sharing and interoperability are critical, panelists repeatedly highlighted the importance of trust, local partnerships, and community-based follow-up.

West Virginia is building a connected ecosystem. From statewide referral networks to HIE expansion and community care hubs, organizations across the state are aligning around shared goals for social care delivery.

A special thank you to everyone who joined us and to our fantastic speakers for sharing their insight, experiences, and vision.

Highlights from the 2026 West Virginia Social Care Summit

This year’s Summit featured 70 participants representing government agencies, healthcare providers, community organizations, and more:

Below are some of the key themes and takeaways from a day of learning and sharing.

Medicaid as a catalyst for statewide transformation

Opening the summit, Christy Donohue, Commissioner of the WV Bureau for Medical Services, discussed how West Virginia Medicaid is helping drive a more coordinated and person-centered approach to care across the state. The conversation focused on how policy direction, partnerships, and statewide priorities are advancing integration between healthcare and social services to improve outcomes for West Virginians.

The keynote framed a recurring theme throughout the day: transformation requires alignment between healthcare, government agencies, and community organizations to create sustainable systems of support.

A vision for an integrated West Virginia safety net

During West Virginia’s Connected Future, Findhelp’s Sr. Director of Healthcare & Public Policy Carla Nelson emphasized the importance of infrastructure and long-term investment in building sustainable social care systems.

“You can’t do the work without infrastructure, dollars, and investments.”

Carla Nelson

Sr. Director of Healthcare & Public Policy

Findhelp

Carla discussed how workflows, partnerships, and shared data are foundational to reducing fragmentation across systems of care. She described Findhelp’s infrastructure as a “single source of truth for social care” and highlighted the broader evolution of connected systems that now include government benefits, social care fulfillment, specialty networks, and integrated ecosystems designed to support whole-person care.

The session also explored emerging innovations, including AI-powered assistance tools designed to improve how people search for and access services. Audience questions focused on interoperability, referral management, and improving communication between providers and community organizations.

From policy to practice across West Virginia

A panel featuring Mirrandia Young of WVU Medicine, Rory Chapman of Marshall Health, Katie Lanham of Vandalia Health Network, and Debra Boyd of WV Primary Care Association explored how organizations across the state are operationalizing social care coordination.

Panelists discussed the administrative burden caused by inconsistent reporting requirements, the challenges of closed-loop referrals, and the importance of creating standardized approaches while still respecting local community workflows.

“This is a very complex thing to try and figure out. Screening is important, but you can not just screen and leave it there. It is shown to be more hurtful to screen and not do anything with it than to not screen in the first place… Not everyone needs the same level of intervention, give people self-help tools and for those that need more help, ensure they get the right help when they need it.”

Mirrandia Young

Manager of Population Health

WVU Medicine

The discussion repeatedly returned to the importance of partnership and shared goals. “What do we all have in common is that we want people to have healthier lives,” said Rory. Speakers also highlighted the realities patients face after discharge and the need for stronger community coordination once individuals leave healthcare settings. “Patients get really lost once they leave the hospital,” Mirrandia explained.

The panel emphasized that while technology can support coordination, local organizations and trusted community relationships remain central to effective care delivery. They also discussed the opportunities presented by the Rural Health Transformation Program and the growing momentum around social care integration statewide.

“Any time you talk about standardizing anything in social care, you need to talk about the local organizations.”

Rory Chapman

Director, FaithHealth Appalachia

Marshall Health

WV Department of Health: Scaling across systems

LeeAnn Blankenship of the West Virginia Department of Health shared how Help Me Grow and West Virginia Connections (powered by Findhelp) are supporting families and strengthening statewide coordination efforts. LeeAnn explained that Help Me Grow functions not simply as a program, but as a system designed to connect families, providers, and community resources through centralized access and navigation support. “Every child deserves the best start, and families thrive when communities work together,” says LeeAnn.

Innovation Grant Report: WV Help Me Grow

Since beginning work with Findhelp in 2022, the initiative has expanded its centralized access model. West Virginai Connections now supports cross-sector referrals across early childhood, public health, clinical, and community-based organizations. Blankenship highlighted the importance of human-centered navigation alongside technology-enabled coordination.

“You can’t just reduce barriers with an email.”

LeeAnn Blankenship

Help Me Grow Coordinator

West Virginia Department of Health

The session emphasized the value of direct outreach, relationship building, and listening closely to families and community partners to improve referral processes and care coordination.

Building connected communities through collaboration

The West Virginia Social Care Summit concluded with a session led by Findhelp’s Marc Coppedge. He highlighted practical strategies for strengthening community collaboration across West Virginia counties.

The interactive session demonstrated how organizations can use shared infrastructure, personalized search folders, and coordinated resource networks to streamline collaboration and improve access to services across local communities.

Throughout the day, one theme remained consistent: meaningful social care transformation depends on bringing organizations together around shared goals, shared infrastructure, and shared accountability for improving outcomes.

As speakers across healthcare, public health, Medicaid, and community organizations reinforced, West Virginia’s path forward is not about replacing relationships with technology. It is about using connected systems to strengthen those relationships and ensure people can access the care and support they need.

Beyond the Summit: Our work in West Virginia

The same day as the Summit, our CEO Erine Gray was interviewed by local TV station MetroNews. He discusses Findhelp’s footprint in West Virginia, a surprising data trend in Parkersburg, and why a staggering 90% of successful connections on the Findhelp platform come from local churches and civic organizations rather than government programs.

Let’s bring Erine Gray into the conversation. Erine, good morning. Thanks for joining us. Good morning. Thanks for having me. Absolutely. So I gave the cliff notes version of what Findhelp is all about, but elaborate a little bit more why you felt this organization was needed. Well, I grew up, in a small town about eight hours directly north by car, about few hours north of Pittsburgh, called Olean, just on the western New York side. And, at a young age, my mom was a janitor at the community college, and she caught a rare disease from a mosquito called encephalitis, back in nineteen ninety two, and, there we were trying to navigate the safety net, and fortunately we were living in a small town where everybody knew each other. My mom had insurance and, we ended up getting through it, but through that life experience, I saw firsthand, several years later when I became her legal guardian, and was her guardian for twenty four years, really just understood, how challenging it was. Know, when you when you, have brain damage as a result of this disease, it leads to a lot of other issues, including mental health issues, for an adult and living that experience, came to the conclusion that we’re a very generous country. We, a lot of nonprofits that are there in these really, really hard situations. But yet if you’re somebody who needs it, you don’t even know where to begin, and, that’s where, over the years decided I want to spend the rest of my life working within the safety net, and, sixteen years ago had the idea, to start Findhelp so that people in need could just, at least know their options, and, you know, once they do understand their options, whether it be a local church, a food pantry, or affordable housing program, or even a government program. Maybe they could use, you know, technology to apply online and get what we call the dignity of a yes or a no. And so that that’s that’s our story, and, that’s what, that we’ve been doing. And how will West Virginia play a role? How do you roll out here? So, in the very early days, so, we’re we’re based in Austin, Texas where I live. We have a team that that researches and enters in every single nonprofit across the United States. We also look at all of the federal and state government programs, whether it’s Social Security or SNAP benefits. We learn all of those eligibility rules, and we did that for the whole country. And so we’ve been live in West Virginia well over twelve years. Oh wow, okay. And so just in the last year, nearly four hundred thousand West Virginians have used our site, whether they’re searching from a cell phone or whether they’re a social worker at one of our customers, West Virginia University Health, are helping people, leaving the hospital, or just somebody that, you know, just wanting to know, hey, what if I lose my job? Am I going to be okay? What services are available for me? Talking to Erine Grey, he is the CEO of Findhelp. What will be happening with the summit that is coming up here? So we’re getting all of our customers together to talk and to basically understand what they’re seeing that’s out there, and that’s actually happening today. We have speakers from the West Virginia Primary Care Association, the Medicaid director here in West Virginia is there, as well as, some folks from WVU Medicine. We’re seeing some really interesting statistics across the state, and I think y’all y’all may appreciate this, with those four hundred thousand users over the last year. Interestingly, I looked at the data, the number one zip code across the entire state where searches were done, was actually in Parkersburg. Really? Which surprised me too. And, when I looked into it a little bit further, it’s, you know, it’s not the biggest town, And it turns out there are a lot of clinics in Parkersburg where people come and they attend the clinics. And then when they leave, they, you know, maybe have gotten better, and they don’t have a place to go. So what you end up seeing is folks just kind of getting out, maybe they’re now sober, and they’re basically trying to figure out what to do next. And, it goes to show the data that we’re seeing goes to show, hey, are there public policy elements of this? Meaning, is there a transition plan after they might finish? Because you have people coming from, all, I think I heard something like when I looked into eighteen different states coming in to attend these clinics. And so, we’re sharing all of that data at our summit, as well as with all of our users so that they can understand, is there something that we’re doing policy wise that can be used? So another quick example is a church, usually is a food pantry, does the food pantries, and they’re not typically open on Sundays because they’re doing things on Sunday. They’re having services. And so what if you looked at the whole, every service that’s offered, and then you’re a foundation, you’re trying to fund it? Sometimes funding of nonprofits happens based on who has the the best proposal or who’s the most well connected. But what if funding was done based on who’s, having the biggest impact? Where is the need? Are they willing to somebody willing to open a food pantry on a Sunday? People are hungry on Sundays too. And so we are making that data available to policymakers all across the country so that they can really think how do you stretch more with the dollars that we do have. I think there’s a big camp of folks that believe that a more efficient safety net is possible and you know, private citizens are a huge part of that, especially the faith based communities. So, really trying to help with the coordination so that people understand, hey, who can I send in this situation? Who can I send in that situation? Because everybody stretched it and it’s across the whole country. There’s a lot of stuff going on right now. We’ve seen search activities higher than we’ve ever seen it even post COVID, even post the government shutdown, last fall. So, I’m a big believer and an optimist that you can do better, with, not spending more federal funding. And so I think more coordination based on data, is gonna be the key, and and I’m optimistic that over time, we can catch people when they’re falling so they don’t end up in even more difficult situations. Anything data driven is better than anything that is not data driven. I mean, that that’s a given, I think. One of the things that’s interesting about your model, you talk not only about federal resources, but you brought up the example of churches and nonprofits and different things. Sometimes those are more timely than what a government solution can be. And if someone is hungry or has a need, there’s a sense of urgency around it where the government may not be able to step in. So you’re bringing everything to the table. And I’m just curious, how much of of what the solution that folks find, through your platform, how much of that is government? How much of that is nonprofit, church, civic, etcetera? What’s the breakout? Well, over ninety percent is civic churches in the whole country. Okay. The government safety net, although it’s large programs Sure. It’s tiny in comparison. And you’re right. It is far more efficient. We work with we use the term seekers, which is anybody seeking services. So we see activity from seekers all the time, and they don’t want to be enrolled in an intrusive government program. Sometimes they just need help getting through a particularly hard time, And when they can spend some time face to face with a human being that sits down, gives them a hug, helps them understand what their options are, they prefer that. And I think most people want to find a job and want to be independent. But what’s amazing is we’re lucky we get to work with social workers every day, all day, and to see their impact, and usually it’s face to face and say, you know, I’ve been there. And a lot of times people who have rose up from very challenging circumstances end up becoming social workers and the cycle is very positive. So I would say most people prefer that close relationship with a local nonprofit. And there’s a lot of redundancy. So we’re seeing some nonprofits merge together. Yeah. And so they could be more efficient. And so you’re right. They’re making decisions based on data with AI and everything else. Tools are now ubiquitous, and I think what the safety net looks like ten years from now is gonna be far better than, you know, what it was ten years ago. One of the things I’m guessing here so if I know there’s a problem, but I don’t know where to go to tackle it, I wanna give to it. I wanna be able to make a meaningful dent foundation or something other. I would be inclined to come to you and say, hey. In this community, given the resources, you probably know where the dollars need to go. Do you ever get any of that? Everybody anybody pick up the phone and say, hey. I I know there’s an issue here. I wanna help make it better, but where do I go? I I get those questions all the time. And, although we don’t have a formal program for that, we can see not only what everybody’s searching for. It’s all anonymous. Sure. But we can also see how responsive every nonprofit is. Okay. So you can imagine someday where a funder says, you know what? I want to make sure that the people that y’all are helping are at least getting a phone call within twenty four hours or they’re responding to those referrals. And we have that data. And so that’s the type of I think of, like, customer service in that in that realm, and it is totally possible, and it could lead to more donations. Erine Gray, Findhelp. We appreciate you coming in today. Thank you. Thank you, sir.

Some numbers that show the scale and momentum

While the Summit provided a rich day of insight and connection, the real work continues — in homes, clinics, schools, and community hubs across the state.

4,892 listed programs serving West Virginia
1 million users across the state
2.4 million searches for resources
100% of counties have claimed programs

As of May 2026, we partner with more than 25 customers throughout the state. They use the Findhelp platform to connect their patients, members, students, constituents, and clients to local resources. Our data and analytic tools can identify gaps in services and provide actionable insights to inform strategy and public policy.

*Searches in West Virginia on Findhelp platforms, Q1-2020 through Q1-2026*

Let’s keep the conversation going

The conversations at the West Virginia Social Care Summit made one thing clear: the future of whole person care depends on connected communities, shared infrastructure, and organizations willing to work together across traditional boundaries.

From Medicaid leaders and health systems to community organizations and care navigators, attendees highlighted both the urgency and the opportunity to build systems that reduce fragmentation and improve outcomes for West Virginians. We’re grateful to everyone who joined the conversation, shared their experiences, and continues to move this work forward across the state. Let’s keep building a more connected future together.

If you’re interested in how Findhelp can support your work — whether you’re a health system, community-based organization, payer, or state agency — we’d love to chat.

Chat with us

Welcome back to our Community Engagement series. In the first three parts of this series, we covered the strategic vision, intelligent workflows, and IT architecture required for Medicaid community engagement. In Part 4, we step outside the government technology stack to address the physical reality of the 2027 requirements: building localized volunteer fulfillment networks and community capacity.

Findhelp policy expert Carla Nelson breaks down Medicaid community engagement requirements.

Under the upcoming Medicaid community engagement requirements, members will have several pathways to fulfill their obligations, including employment, job training, education, and community volunteering.

While employment or education can be documented through income verification, pay stubs or enrollment records, community volunteer fulfillment presents a distinct operational hurdle.

In this post, you’ll learn:

Why logging hours via tools like CMS Emmy is only half the battle, and why a localized resource network is required to bridge the fulfillment gap.

How to map geographic supply against member demand to ensure your program is equitable, sustainable, and legally defensible.

Strategies to prevent administrative burnout for community partners by integrating verification into their existing workflows.

The challenges with community volunteer fulfillment

Community organizations offering volunteer opportunities are highly localized and frequently operate independently. Because a cohesive network does not naturally exist, there is rarely a centralized way to identify available volunteer opportunities, seamlessly navigate members to open slots, or efficiently track and verify the hours completed.

This lack of underlying infrastructure creates a specific operational challenge for key stakeholders across the Medicaid ecosystem:

For the Medicaid Member

A member must independently locate a qualifying organization with open volunteer slots within a reasonable transit radius, secure a position, and manually track hours on paper forms. For individuals already navigating significant social barriers, this logistical complexity creates even more hurdles.

For the Managed Care Organization (MCO)

MCO care managers lack a consolidated, real-time directory of active community programs. Without visibility, they are left manually calling local food banks to find open slots, making it nearly impossible to actively navigate members to the right resources.

For the State Agency

If a state lacks a centralized view of volunteer capacity, it becomes incredibly difficult to administer the program equitably. This lack of visibility leaves agencies vulnerable to high volumes of appeals when members in rural or under-resourced areas face coverage disruptions simply because there were no local opportunities available.

Implementing a sustainable community engagement program requires solving this volunteer fulfillment gap. States and health plans must look beyond their eligibility systems and focus on how they actually connect members to the community.

Reporting vs. resourcing: Navigating federal tools

Recognizing the administrative workload of these new rules, the Centers for Medicare & Medicaid Services (CMS) released Eligibility Made Easy (Emmy), a suite of open-source tools to streamline the reporting of compliance hours.

While Emmy addresses a critical data-entry need by providing a mobile-responsive interface for beneficiaries to log activities, states must distinguish between reporting an activity and resourcing it:

Reporting (CMS Emmy): Provides a streamlined mechanism for a member to submit their 80 hours to the state.
Resourcing (Findhelp): Provides the network required to find those 80 hours, supplying localized directories of open volunteer shifts and adult education classes.

If states deploy reporting tools without connecting members to actual opportunities, they risk unnecessary coverage disruptions while failing to advance the core policy goals of self-sufficiency and workforce readiness.

The Findhelp standard: Community Engagement Network Adequacy

In Medicaid managed care, states and health plans rigorously monitor clinical network adequacy, ensuring sufficient primary care and specialist capacity within a reasonable distance for all members.

Community engagement introduces the parallel need for Community Engagement Network Adequacy.

To support volunteer and training requirements, states need a clear picture of local capacity. By overlaying the geographic distribution of at-risk Medicaid members with Findhelp’s network of active community programs, states and MCOs can map supply against demand.

Protecting the community ecosystem

Local food banks, shelters, and community centers are the backbone of these requirements. Yet, these organizations frequently operate at maximum capacity with limited staff.

An uncoordinated influx of individuals seeking to meet their volunteer hours risks straining these critical partners. Furthermore, if participating in a state’s Medicaid requirements means a CBO director must navigate disparate government portals or manually sign off on paper timesheets, many may simply decline to accept these volunteers.

To mitigate this systemic strain, Findhelp’s infrastructure provides CBOs with the operational tools necessary to manage their own capacity:

Capacity Management: Participating CBOs can set defined limits on available volunteer slots or training programs. When capacity is reached, organizations can pause incoming referrals, automatically diverting traffic to other programs with open availability.

Verification within Existing Workflows: As states move toward third-party verification, asking community partners to log into a separate, net-new government portal just to verify hours creates unnecessary administrative strain. By leveraging a platform that CBOs already use to manage broader social needs (like food and housing referrals), verification happens organically. When a member completes their hours, the CBO confirms participation directly within their existing Findhelp workflow, eliminating double data entry.

The “Closed Loop” Record: This confirmation generates a verifiable, third-party data point that can flow automatically to the MCO, the State E&E system, or seamlessly into reporting tools like CMS’s Emmy.

Proof in practice: Operationalizing network adequacy

Sourcing, vetting, and onboarding thousands of local volunteer sites is a resource-intensive undertaking. A modern infrastructure must include a pre-existing, actively managed network that captures compliance data within the exact same system used to manage a member’s broader health-related social needs (HRSN).

This concept is already solving adjacent policy challenges today. For example, certain SNAP beneficiaries in Pennsylvania face similar 80-hour-per-month work, education, or volunteer fulfillment requirements.

Faced with this fulfillment gap, the Pennsylvania Department of Human Services (DHS) leveraged PA Navigate, a statewide community information network powered by Findhelp. SNAP recipients can log into the platform they already use for social support, enter their ZIP Code, and identify local organizations with open volunteer slots.

Finding and connecting to volunteer fulfillment opportunities is easy on the Findhelp platform.

This approach gives members a clear pathway to compliance, provides the state with visibility into localized volunteer capacity, and protects CBOs from new administrative burdens.

A sustainable path forward for volunteer fulfillment

Community engagement requirements without an accurate and responsive network place a significant strain on community resources. Open-source reporting tools and modern E&E systems are essential, but they function solely as the administrative framework. The actual viability of the program depends on easily identifying and navigating the localized supply of community opportunities.

By using Findhelp to identify volunteer fulfillment opportunities, measure Community Engagement Network Adequacy, protect CBO capacity, and seamlessly integrate third-party verification into existing workflows, states can ensure that community engagement operates as a sustainable pathway to economic mobility.

Talk to our team

What’s next?

Now that we’ve mapped the strategic vision, the workflow, the architecture, and the community network, how do we structure the underlying data to make all of this interoperable?

In Part 5, we will conclude our series by breaking down the data model that powers the future of Medicaid.

Iowa isn’t waiting around for the future of social care to arrive politely. It’s building it in real time, with urgency, experimentation, and a willingness to rethink systems from the ground up. At the Iowa Social Care Summit, state leaders, healthcare organizations, and community partners came together to explore what it takes to turn historic funding into lasting impact.

From rural health transformation to data-driven decision making and community-led coordination, one theme echoed throughout the day: progress happens when systems connect and people stay at the center.

Read on for key takeaways:

Rural transformation requires bold investment and new thinking: Iowa is moving quickly to deploy historic funding across technology, workforce, and community-based care models.

Data is becoming the backbone of social care strategy: From reimbursement to program design, integrated data systems are reshaping how impact is measured and scaled.

Community coordination is the difference-maker: Care hubs, cross-sector partnerships, and shared infrastructure are turning fragmented services into cohesive support systems.

A special thank you to everyone who joined us and to our fantastic speakers for sharing their insight, experiences, and vision.

Highlights from the 2026 Iowa Social Care Summit

This year’s Summit featured 40 participants representing government agencies, healthcare providers, community organizations, and more:

Below are some of the key themes and takeaways from a day of learning and sharing.

Transforming rural health: Iowa’s Healthy Hometowns

Larry Johnson, Director of Iowa DHHS, opened with a clear message: transformation isn’t optional, it’s already underway.

With Iowa ranking among the most rural states in the country, the stakes are high. The state secured more funding than requested through the Rural Health Transformation Program and is already moving faster than most.

“We don’t put the technology on bad processes,” Larry said. That philosophy is shaping how Iowa approaches its five pillars, including expanding screening access, co-locating services, modernizing health information exchange, and investing in community-based care models like the HOME Project.

The state is also rethinking how residents interact with public benefits through its Economic Mobility Strategy, aiming to make systems easier to navigate and more responsive to real-life needs.

“Sometimes navigating for resources can become a trap, so how can the State make it easy to navigate and take a whole person approach?”

Larry Johnson

Director

Iowa Department of Health and Human Services

And the urgency is real. Funds must be deployed quickly or risk being reallocated.

The result is a state moving at full speed, testing new models, modernizing infrastructure, and pushing beyond traditional boundaries to better serve rural communities.

A vision for an integrated Iowa safety net

Erine Gray brought the conversation into focus with a vision grounded in dignity, data, and scale.

“Everyone deserves the dignity of a ‘yes’ or ‘no’.”

Erine Gray

Founder & CEO

Findhelp

That principle sits at the core of building a modern social care ecosystem. For decades, healthcare has relied on standardized codes and reimbursement structures, while social care has operated without the same infrastructure. That gap is beginning to close.

Through integrated data, case management tools like Kiip, and eligibility solutions like Uno Health, Iowa and other states are beginning to connect fragmented systems into a more unified experience.

At the same time, innovation is accelerating. From AI-powered search and summarization to shared longitudinal records and real-time eligibility screening, technology is expanding what’s possible while raising important questions about workforce, trust, and implementation.

The goal isn’t to replace human connection, but to strengthen it with better tools, better data, and better coordination.

How managed care is transforming social care delivery

Melody Walter, Director of Quality Management at Wellpoint, shared how managed care organizations are playing a critical role in turning strategy into action.

She shared a real member story that captured the impact of coordinated care: a young, pregnant woman was experiencing homelessness and living in her car. Case managers were able to help connect her to resources via Findhelp, leading to a healthier birth outcome and more stable housing situation for both mom and baby.

At the same time, Melody highlighted ongoing challenges, including housing instability, rising food insecurity, and the complexity of managing chronic conditions alongside social needs.

The message to providers and partners was simple: make the referrals, share the platform, and build awareness.

Integrated care only works when the system is actively used.

Powering whole person care through HIE innovation

As Iowa transitions to a new health information exchange (HIE), the focus is on building infrastructure that supports real-time, cross-sector coordination.

Laura Young, Executive Director of Converge Heath, shared how HIEs are evolving beyond clinical data to include social care information, enabling:

Timely access to patient data

Better coordination across organizations

Reduced gaps in care transitions

More complete, shared understanding of individual needs

But challenges remain, particularly around privacy, consent, and integrating sensitive data like substance use information.

The opportunity is clear: when data flows seamlessly and securely, care becomes more proactive, coordinated, and effective.

Stronger together: The role of community care hubs

If data is the backbone, community care hubs are the connective tissue.

Across Iowa, hubs like Quad Cities Open Network and Iowa Community Hub are helping translate referrals into real-world support. Community health workers receive referrals, assess needs, and connect individuals to the right services.

HUB Navigators have helped enroll more than 4,500 people in services, demonstrating the power of coordinated, community-based care.

Programs like the HUB Produce Box initiative are addressing barriers head-on, delivering 2,000 boxes of fresh food directly to individuals since 2021, and improving both access and outcomes.

But beyond the metrics, speakers emphasized trust, transparency, and shared purpose. Iowa Community Hub invited 160 staff from local critical access hospitals to a training to show clearly how the Hub would work with Findhelp.

“[We build relationships by] being transparent with organizations. We have their back; we’re here.”

Ernesta Martinez

Community HUB Navigator

Iowa Community Hub

Similarly, Cecilia Bailey from Quad Cities Open Network emphasized face-to-face time and including demos of the Findhelp platform to show how easy it is to use. And, perhaps most importantly, Cecelia discussed how a shared mission is what allows organizations to move beyond competition and toward collaboration.

“The biggest challenge in improving care coordination is reminding each other that we all want our communities to be strong and so we are not opponents. We need to be working together.”

Cecelia Bailey

Executive Director

Quad Cities Open Network

Cecelia also focused on quality measurement rather than quantity measurement. “The sheer numbers is not what does it – it’s whether or not outcomes are met”.

Beyond the Summit: Our work in Iowa

While the Summit provided a rich day of insight and connection, the real work continues — in homes, clinics, schools, and community hubs across the state.

Some of the numbers that show the scale and momentum:

5,675 listed programs serving Iowa
940 thousand users across the state
2.5 million searches for resources
100% of counties have claimed programs

As of May 2026, we partner with more than 20 customers throughout the state to connect their patients, members, students, constituents, and clients to local resources. Our data and analytic tools can identify gaps in services and provide actionable insights to inform strategy and public policy.

*Searches in Iowa on Findhelp platforms, Q1-2020 through Q1-2026*

Let’s keep the conversation going

Throughout the Iowa Social Care Summit, one reality was impossible to ignore: the challenges ahead are complex, but the foundation for progress is already in place.

From statewide funding strategies to local community hubs, Iowa is building a system designed not just to respond to needs, but to anticipate and address them more effectively. The path forward will require continued collaboration, sustained investment, and a willingness to evolve. But the direction is clear.

A more connected, coordinated, and community-centered system isn’t just possible. It’s already taking shape.

If you’re interested in how Findhelp can support your work — whether you’re a health system, community-based organization, payer, or state agency — we’d love to chat.

Chat with us

Each episode offers an inside look at the systems, decisions, and ideas driving change—and what it takes to build a social safety net that works at scale.

Emergency departments are built for urgent care. But for many patients, an ED visit is just the visible tip of something deeper—unmet social needs, fragmented systems, and gaps in ongoing support.

In this episode of No Wrong Door, Vidya Lakshminarayanan, COO of Connxus (a health information exchange in Central Texas), shares how her team is transforming that moment after an ED visit into an opportunity: combining real-time data, community health workers, and coordinated referrals to connect patients to the care they actually need.

In this episode, we explore:

Emergency department utilization often reflects unmet social and systemic needs—not just acute medical issues

Health information exchanges (HIEs) can unify fragmented patient data into a single, actionable story

Community health workers play a critical role in building trust and ensuring referrals turn into real outcomes

Watch episode 7: “The Power of Follow-Up”

Key themes from the conversation

Emergency visits as signals, not endpoints

For many patients, an ED visit isn’t the beginning or the end of care—it’s a flare sent up from a system under strain.

Connxus treats these visits as indicators of deeper gaps, from lack of primary care access to unmet basic needs.

By identifying high utilizers and intervening after discharge, the team shifts from reactive care to proactive support.

“It’s not just about what’s happening in a person’s life on a day-to-day basis… it’s about how different things come together to shape a person’s life.”

Vidya Lakshminarayanan

COO at Connxus

Turning data into a patient story

Patients are often expected to retell their story over and over across providers. Connxus uses HIE data to eliminate that burden—aggregating clinical and social data into a unified, longitudinal view.

This isn’t just about efficiency. It’s about clarity and better care decisions at every touchpoint.

“We become your storytellers. You don’t have to remember the story… we link your data and deliver it to providers at the time of care.”

Vidya Lakshminarayanan

COO at Connxus

Community health workers: Closing the loop through human connection

Data can identify needs—but it can’t build trust. That’s where community health workers (CHWs) come in.

Connxus pairs its data infrastructure with a CHW program that reaches out to patients after ED visits, screens for social needs, and follows up over a six-month period.

This sustained engagement turns referrals into real outcomes.

“It’s not just a referral anymore. It becomes more impactful when you can show the outcome.”

Vidya Lakshminarayanan

COO at Connxus

Measuring what matters: Outcomes, not outputs

Connxus tracks success beyond outreach—focusing on engagement, navigation, and whether patients actually receive help.

The results are promising: most patients reduce preventable ED visits after participating in the program, demonstrating the real impact of coordinated social care interventions.

“Clearly there is a relationship between the social interventions that we are providing and the health care outcomes that we are seeing.”

Vidya Lakshminarayanan

COO at Connxus

The persistent fragmentation of social care

Even as innovation accelerates across healthcare, social care remains deeply fragmented—often disconnected from the clinical systems patients rely on most.

That gap isn’t just operational; it shapes outcomes, access, and patient experience.

No Wrong Door host Amy Gordona underscores a tension many in the field recognize: we’ve made progress, but not nearly enough. Bridging that divide isn’t just a technical challenge—it’s a systemic one.

“I’m always amazed that in 2026, this particular area of care… is still so fragmented from the rest of the services we all receive.”

Amy Gordona

VP of Marketing at Findhelp and host of ‘No Wrong Door’

This fragmentation is exactly what models like Connxus aim to solve—by aligning data, people, and partnerships into something that feels less like a maze and more like a pathway.

Learn more about Connxus’ work

Several of Vidya’s colleagues from Connxus will be presenting at the upcoming Connect Summit on May 13-14, discussing vital role of Community Health Workers in shifting patients from emergency care to sustainable primary and community-based support.

Build Trusting Relationships: Learn how telephonic outreach and Findhelp program cards empower frontliners to engage vulnerable populations effectively.
Close the Care Loop: Identify practical workflows for tracking patient follow-ups and graduation to ensure long-term transitions from the ED to community resources.

Connect Summit 2026 | How Connxus is reducing preventable ED visits by combining HIE data and community health workers.

Register for the Summit

**What’s next for No Wrong Door?**

“The Power of Follow-Up” is available now—Episode 8 will be released on May 11 and features MiResource co-founder Mackenzie Drazan talking about how better data and smarter infrastructure can revolutionize behavioral health referrals.

Subscribe to No Wrong Door wherever you listen to podcasts to be notified when new episodes drop:

In New Mexico, systems are being rewired with intention. Not just to refer, but to respond. Not just to build infrastructure, but to build trust. At the New Mexico Social Care Summit, leaders across state agencies, healthcare, and community organizations came together around a shared premise: connection is the work.

Read on for key takeaways:

Connection is the intervention: Better outcomes don’t come from more programs alone, but from systems that are truly connected and accountable to what happens next.

Community-led design is essential: New Mexico’s approach centers relationships, culture, and local leadership as the foundation for building an effective social care ecosystem.

Data + collaboration = direction: From managed care to community-based organizations, shared data is beginning to shape smarter investments, reveal gaps, and guide coordinated action statewide.

A special thank you to everyone who joined us and to our fantastic speakers for sharing their insight, experiences, and vision.

Highlights from the 2026 New Mexico Social Care Summit

This year’s Summit featured 96 participants representing government agencies, healthcare providers, community organizations, and more:

Below are some of the key themes and takeaways from a day of learning and sharing.

A system rooted in lived experience

Kathy Slater-Huff, Deputy Cabinet Secretary of the New Mexico Health Care Authority, opened the Summit with a story that grounded the day in something deeper than policy.

“No matter how hard my dad worked, he still needed help. This work is personal, it’s about people, it’s about dignity, and connection.”

Kathy Slater-Huff

Deputy Cabinet Secretary, New Mexico Health Care Authority

Her experience navigating public assistance as a child shaped her understanding of today’s systems—and their gaps. “The not knowing was not unique, it was and is the pattern”, she said. That pattern is exactly what New Mexico is working to change through YesNMConnect: a unified, statewide approach to social care, one with “no wrong doors and no dead ends”.

At its core, this work is about designing systems that reflect the realities of the people they serve. Kathy emphasized, “When systems are connected, people don’t have to repeat their stories”.

And doing so in a way that honors the state’s diversity, the diverse cultures, traditions, and strengths that define the state of New Mexico. The vision is clear: move from fragmented transactions to coordinated care that feels human.

“Building a system that is responsive, not reactive. Relational, not transactional.”

Kathy Slater-Huff

Deputy Cabinet Secretary, New Mexico Health Care Authority

From referrals to real outcomes

Across sessions, one theme echoed: referrals alone are not enough. In a panel on public health and aging, speakers like Susan Garcia, Director of Health Equity at the New Mexico Department of Health, highlighted how a connected system can fundamentally change outcomes.

“When clinical providers make referrals to social care, it’s a powerful thing… The more we learn about healthcare, the more we realize how much of what predicts an individual’s outcomes is related to the social drivers of health.”

Susan Garcia

Director of Health Equity, New Mexico Department of Health

But without visibility into what happens next, that power is limited. “All too often in systems, we give people this information, and that person goes away and we have no idea what happened to them”, Susan said.

A connected, statewide platform changes that equation, and replaces outdated workflows that have long defined social care. As Susan puts it: “Reducing the sticky note referral. They’re really hard to track. This will allow us to change that way of working”.

In a geographically vast state, connection also helps overcome distance itself, as people may travel hours to receive care.

Building the network, together

In communities like Curry County, implementation is already taking shape.

Local leaders are bringing together cross-sector partners, training teams, and embedding YesNMConnect (the state’s social care platform, powered by Findhelp) into everyday workflows. The work is both practical and deeply collaborative, focused on reducing fragmentation and increasing follow-through.

At the same time, initiatives like Project ECHO are expanding capacity across the state by sharing knowledge rather than relocating resources, and reinforcing a model of shared learning.

“All of us teach and all of us learn.”

Crystal Morales

Sr. Program Manager, Project ECHO

This approach is helping organizations that once operated in isolation become part of a broader, more coordinated network.

Data as a compass for action

For managed care organizations, the shift toward connected systems is unlocking new ways to understand and respond to member needs. By integrating social care data directly into care coordination workflows, teams can identify gaps, track outcomes, and refine programs in real time.

“What’s the dose we need to get somebody to thrive? How much housing, food, transportation do we need? We cannot be resource-dumb. We can’t be putting resources into the same things and miss other areas that would have a greater impact.”

Kyra Ochoa

Long Term Care Division Director, New Mexico Aging & Long-Term Services Department

The ability to compare referral fulfillment, analyze engagement, and identify resource deserts is already shaping how organizations allocate funding and prioritize interventions. Just as importantly, collaboration across MCOs is becoming a defining feature of the work.

Shared goals, coordinated outreach, and aligned strategies are helping reduce duplication and create a more seamless experience for both members and community-based organizations.

Still, speakers emphasized that data alone isn’t enough. It must be paired with:

Real investment in community organizations
Clear communication
Consistent training
Strong feedback loops

Designing for trust, not just technology

The closing keynote brought the conversation back to what matters most: people.

Dr. Rohini McKee shared a story that illustrated the consequences of disconnected systems—and the opportunity to reimagine them.

“Re-imagine the story of the woman who came to the hospital. Everyone in the story was doing the right thing – the clinic called her, the system was ready for her emergency care. Reimagined, you have the same people, same resources, and same story, just connected.”

Dr. Rohini McKee

Chief Quality & Safety Officer, University of New Mexico Hospital

She challenged attendees to think beyond tools and referrals, and instead focus on designing systems that people trust.

The stakes are high. When systems fail to connect, the impact is felt across the entire continuum of care: “We are the state’s hospital. When care is fragmented, it shows up at our doorstep,” said Dr. Rohini.

But the path forward is within reach.

“We can’t fund our way out of this, or hire our way out of this, we have to connect our way through this.”

Dr. Rohini McKee

Chief Quality & Safety Officer, University of New Mexico Hospital

Beyond the Summit: Our work in New Mexico

While the Summit provided a rich day of insight and connection, the real work continues — in homes, clinics, schools, and community hubs across the state.

Some of the numbers that show the scale and momentum:

3,419 listed programs serving New Mexico
690,000 users across the state
1.8 million searches for resources
6,300 social needs assessments completed
100% of counties have claimed programs

As of April 2026, we partner with more than 35 customers throughout the state to connect their patients, members, students, constituents, and clients to local resources. Our data and analytic tools can identify gaps in services and provide actionable insights to inform strategy and public policy.

*Growth in searches in New Mexico on Findhelp platforms, Q1 2021 through Q1 202*6

Where New Mexico social care goes from here

The summit closed with a clear sense of momentum. New Mexico is not starting from scratch. It is building on relationships, resilience, and a shared commitment to doing things differently. The blueprint is taking shape. Now, the work is to keep connecting the dots.

“Transformation doesn’t happen at the policy level alone. It happens in the moments when we choose to act together, in community, in a system built in New Mexico.”

Kathy Slater-Huff

Deputy Cabinet Secretary, New Mexico Health Care Authority

If you’re interested in how Findhelp can support your work — whether you’re a health system, community-based organization, payer, or state agency — we’d love to chat.

Chat with us

Watch episode 9: “Creating Connected Communities”

Key themes from the conversation

Retiring the resource binder

Cultivating radical collaboration and community ownership

The art of “slow baking” community & CBO engagement

Turning search analytics into tangible county public health resources

How Denton County Created a Community-Wide Solution for Social Care

What’s next for No Wrong Door?

Ready to modernize your social care workflows?

Let’s chat!

Highlights from the 2026 Pennsylvania Social Care Summit

Pennsylvania’s smarter safety net

Medicaid’s new frontier: Navigating the 2026 funding shifts

Dignity by design: Leading with empathy

“No wrong door” in action: Scaling PA Navigate through HIE collaboration

Community at the center: Elevating Pennsylvania CBO voices

Beyond the Summit: Our work in Pennsylvania

Some numbers that show the scale and momentum

Let’s keep the conversation going

Watch episode 8: “Closing the Behavioral Health Gap”

Key themes from the conversation

The hidden complexity behind behavioral health referrals

Behavioral health access is usually a data problem

The process often breaks after the referral is made

Connected behavioral health networks for whole person care

What’s next for No Wrong Door?

PCA Georgia + Find Help Georgia

Fostering intentional community relationships

TennCare

Leading implementation of a statewide social care infrastructure

Dallas College

Improving student persistence by 70% with Findhelp Fulfillment

Thank you to our awardees

Highlights from the 2026 West Virginia Social Care Summit

Medicaid as a catalyst for statewide transformation

A vision for an integrated West Virginia safety net

From policy to practice across West Virginia

WV Department of Health: Scaling across systems

Building connected communities through collaboration

Beyond the Summit: Our work in West Virginia

Some numbers that show the scale and momentum

Let’s keep the conversation going

The challenges with community volunteer fulfillment

Reporting vs. resourcing: Navigating federal tools

The Findhelp standard: Community Engagement Network Adequacy

Protecting the community ecosystem

Proof in practice: Operationalizing network adequacy

A sustainable path forward for volunteer fulfillment

What’s next?

Highlights from the 2026 Iowa Social Care Summit

Transforming rural health: Iowa’s Healthy Hometowns

A vision for an integrated Iowa safety net

How managed care is transforming social care delivery

Powering whole person care through HIE innovation

Stronger together: The role of community care hubs

Beyond the Summit: Our work in Iowa

Some of the numbers that show the scale and momentum:

Let’s keep the conversation going

Watch episode 7: “The Power of Follow-Up”

Key themes from the conversation

Emergency visits as signals, not endpoints

Turning data into a patient story

Community health workers: Closing the loop through human connection

Measuring what matters: Outcomes, not outputs

The persistent fragmentation of social care

What’s next for No Wrong Door?

Highlights from the 2026 New Mexico Social Care Summit

A system rooted in lived experience

From referrals to real outcomes

Building the network, together

Data as a compass for action

Designing for trust, not just technology

Beyond the Summit: Our work in New Mexico

Some of the numbers that show the scale and momentum:

Where New Mexico social care goes from here

**What’s next for No Wrong Door?**

**What’s next for No Wrong Door?**

**What’s next for No Wrong Door?**