Candace Stohs-Krause, Author at Findhelp

Findhelp + AIDA: Streamline Post-Acute Care Referrals

We’re proud to announce a new partnership with AIDA Healthcare. The Findhelp + AIDA integration is a powerful solution that bridges the gap between healthcare organizations and post-acute care (PAC).

Together, we support seamless referral workflows to a comprehensive network of PAC providers, including skilled nursing facilities, home health agencies, hospice agencies, and more.

Introducing the Findhelp + AIDA partnership.

Keep reading to learn about:

How Findhelp + AIDA can reduce administrative burden and costs

Improving care transitions with Findhelp + AIDA

Ways to implement this seamless integration

Power seamless post-acute care transitions

AIDA simplifies the complexity of patient placement so that case managers and patients clearly know the next step—driving better decisions that ultimately lead to better outcomes for the patient.

When information and communication are clear, better choices are made—increasing efficiency while reducing length of stay and readmissions.

Data-driven decisions like these are the backbone of value-based care. AIDA facilitates informed decisionmaking by providing important details about downstream providers and a technology-driven approach to communicating with them.

The Findhelp + AIDA integration simplifies processes, lessens administrative work, and ensures the efficient flow of necessary information, enabling timely placements and supporting informed patient choice – a key regulatory and satisfaction driver.

“Our partnership with AIDA Healthcare reflects our commitment to simplifying the most complex care transitions. By integrating AIDA’s post‑acute referral workflow into our full-stack social care platform, we’re enabling our customers to deliver whole‑person care more efficiently and effectively.”

Erine Gray

Founder and CEO, Findhelp

Costly, inefficient post-acute referrals & prolonged hospital stays

Manually sharing patient data for PAC referrals is time-consuming and inefficient, often involving outdated methods like faxing. These delays not only increase administrative overhead for both hospitals and PACs but also contribute to increased length of stay, potentially hindering access for other patients and increasing ED wait times.

Unlock efficiency and reduce length of stay

The Findhelp + AIDA integration provides an automated solution for sharing required patient information with PAC providers. Leveraging the AIDA app, Findhelp Launch users will be able to send applicable records to PACs. This streamlined process empowers hospitals to expedite referrals, facilitating quicker transitions to the appropriate level of care and significantly reducing the length of stay for patients.

The platform is also designed to support informed patient choice by ensuring PAC providers have the necessary information to engage patients and their families in the decision-making process.

Drive positive outcomes: Organizational benefits

Reduced Administrative Labor
- Eliminate the manual steps involved in selecting, processing, and sharing patient records for each referral.

Improved Efficiency
- Streamline referral workflows, allowing your staff to focus on core responsibilities rather than administrative tasks.

Enhanced Data Accuracy
- Ensure PAC providers receive the complete and up-to-date information they need for informed decision-making.

Faster Referral Processing
- Enable PACs to quickly access necessary records, leading to quicker acceptance and smoother transitions for patients.

Reduced Readmissions
- Facilitating more informed and appropriate PAC placements through comprehensive data sharing contributes to fewer readmissions, further improving the overall care transition process.

“We built AIDA to bring clarity, quality, and speed to post-acute referrals, and partnering with Findhelp strengthens that mission. Findhelp’s leadership in social care makes this a natural fit. Together, we’re connecting clinical and social care in one modern workflow — removing silos and helping teams move patients to the right next level of care faster and with far less friction.”

Julian Paraschiv

Founder and CEO, AIDA Healthcare

Watch: Findhelp + AIDA in action

See AIDA in action—watch the recording of our joint session at the 2025 Connect Summit social care conference, “Unlock Seamless Post-Acute Referrals: The Power of Findhelp + AIDA”.

Partnering for Better Care Transitions

Findhelp’s partnership with AIDA Healthcare underscores our commitment to providing innovative solutions that simplify complex healthcare processes and improve patient outcomes. By easily connecting referring organizations with post-acute care providers through integrated data sharing, we’re facilitating smoother transitions and enhancing the quality of care.

Is Findhelp + AIDA right for you?

This powerful integration is ideal for healthcare organizations that:

Prioritize the accuracy and security of patient data during referrals
Routinely refer patients to post-acute care facilities
Are seeking to reduce the administrative burden on case management teams.

Get started

Findhelp and AIDA Healthcare are rolling out new capabilities and integrations designed to accelerate care transitions and improve both operational and clinical outcomes. Interested providers, health systems, and payers can schedule a demo to explore how this partnership can transform their post‑acute referral workflows.

Connect with your Findhelp account representative or chat with a Findhelp team member to learn more about enabling Findhelp + AIDA and customizing it to your organization’s specific needs.

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Northern California Social Care Summit: Highlights from the Golden State

We were thrilled to bring together so many dedicated leaders from healthcare systems, community-based organizations (CBOs), and public health departments for our Northern California Social Care Summit. The day was filled with energy, candid conversations, and a powerful, shared commitment to building a more connected social care ecosystem for all Californians.

A special thank you to all our attendees and incredible speakers for sharing their insights. The path to navigating complex policies like CalAIM and addressing statewide needs is built through the collaboration and innovation we saw on display.

Read on for key takeaways:

Sutter Health shared its successful pilot that integrated social needs screening in mental health care by leveraging EHR data and staff training.

A CalAIM panel stressed breaking down silos, forming true CBO partnerships, and using Community Health Workers (CHWs) to build trust.

Another panel highlighted essential CBOs, like Rosarium Health and Mom’s Meals, providing critical “boots on the ground” community services.

Highlights from the 2025 California Social Care Summit

This year’s Summit featured 32 participants from 22 organizations across Northern California, representing county government, health care, nonprofits, and more.

A sincere thank you to all our speakers and attendees for a day filled with candid conversation and a shared commitment to strengthening the social safety net for every Californian.

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

Our vision for a connected California

The California Social Care Summit kicked off with a look at Findhelp’s vision for an end-to-end social care ecosystem. We highlighted our full suite of tools—Findhelp, Kiip, SchoolCare, and our benefits eligibility platform, Uno—and how they work together to create a seamless social safety net.

We explored the expansion of our platform into a unified digital infrastructure, from identifying social needs, coordinating services, and managing benefits enrollment to service fulfillment and specialized networks for post-acute care and behavioral health. This allows partners to not only refer but also authorize, manage claims, and process reimbursements for services, all in one place—a critical function for 1115 Waiver work like CalAIM.

The impact in California is already immense:

8 million users across the state
20 million searches logged
A powerful spike in searches for housing and food during the Los Angeles-area fires, demonstrating the network’s vital role as a real-time crisis response tool.

We are actively supporting California’s landmark policies, including CalAIM, Governor Newsom’s Children and Youth Behavioral Health Initiative (CYBHI), and SB 660: California Health and Human Services Data Exchange Framework, to help build the integrated infrastructure the state needs.

From the ground up: Sutter Health’s patient-centered pilot

Juan Carlos Piña, Program Manager at Sutter Health, provided a transparent, on-the-ground look at how a major health system begins their social care journey. Grounding his presentation in the fact that 80% of health is tied to social needs, Juan Carlos detailed Sutter’s multi-year strategy to drive quality by building the right infrastructure.

Sutter’s pilot at the Center for Psychiatry focused on a core goal: leveraging Findhelp to connect adult acute care patients with mental health diagnoses to the right community programs. This group is 2x less likely to be screened, but 2.5x more likely to screen positive, highlighting a major service gap.

Key successes and takeaways:

A Clear Strategy: Sutter’s approach followed a linear path:
- Build the infrastructure via EHR workflows
- Collect data via screening forms
- Populate dashboards with analytical insights
- Inform interventions
Data-Driven Focus: Early data from the pilot was compelling. Of 1,355 eligible patients, more than 1,000 completed screeners, and of those 227 (20%) screened positive for at least one social need.
Building CBO Partnerships: Juan Carlos emphasized that community engagement “takes time and should be done well.” His team identified 26 key CBOs and prioritized them in phases, starting conversations with a “less is more” email approach to build trust and assess capacity.

To ensure staff were prepared, Sutter Health’s leadership mandated a 25-minute training module. The result was a 97% completion rate, empowering staff across the hospital to understand and effectively use the Findhelp platform.

From policy to practice: Navigating CalAIM and CBO partnerships

Our next panel dove straight into one of California’s most significant and complex initiatives: CalAIM. We heard from leaders at the San Francisco Department of Public Health and San Francisco Health Plan (SFHP).

The discussion focused on the central challenge: breaking down historic silos to build a truly person-centered system.

Key themes:

Building True Partnerships: Tina Yu of SFHP stressed that they seek partners with a trusted community reputation and vital cultural and language competencies. The panel discussed moving beyond a “contracted provider” mindset to one of true partnership, with managed care organizations (MCOs) working together to streamline processes for CBOs. SFHP used a dedicated team to establish CBOs as genuine “partners” and demonstrate a mutual, long-term commitment.
Barriers to Working Together: The primary barrier to trust and collaboration is the historical disconnect and lack of a “common language” between social organizations and health plans, which requires proactive communication to establish a shared understanding and align on common goals.
The Power of CHWs: The panel affirmed the essential role of Community Health Workers (CHWs) with lived experience in building trust, especially with members who “have negative experience with their health plans.”

Community organization spotlight: Local partners leading social care innovation

This panel highlighted several CBOs who participate in CalAIM as service providers, partnering with MCOs and the state to meet the needs of Medicaid members. From providing cognitive support for the elderly, complex home modifications, culturally-competent cancer support for the LGBTQIA+ community, and medically-tailored meals for hard-to-reach (e.g., rural) individuals, these CBOs are making a difference in Northern California.

Key themes:

Simplifying System Navigation: Health and social benefits are “incredibly hard to navigate”; these organizations act as essential partners to streamline complex processes, overcome bureaucratic hurdles (like documentation or landlord consent), and manage the “whole person” rather than a single problem.
Emphasis on Personalized, High-Touch Support: The presenters championed a “trusted and personal” community-embedded approach—such as visiting every client or using humor to build trust—to counter impersonal systems and meet the unique needs and family dynamics of each individual.
Findhelp as Critical Infrastructure: The panelists consistently identified Findhelp as the essential technology partner that solves a primary challenge for CBOs: being found. It acts as the “answer” for connecting with social workers, health plans, and more to manage shared referrals and clients.

Powering a smarter, more connected safety net

The California Social Care Summit concluded with a look at the technology that powers this ecosystem. We highlighted Kiip, our free case management platform for CBOs. We’ve full integrated Kiip into Findhelp, with features like a document locker and chat rooms so navigators can communicate with clients.

We also explored the tools that enable the complex work discussed all day:

Payment functionality to manage claims and reimbursements for waiver programs like CalAIM.
Payer match capabilities and membership status widgets to help navigators find in-network services.
Findhelp Coalitions, which create a shared longitudinal social care record to reduce duplicative efforts and provide a true whole-person view.

Beyond the Summit: Our work in California

Our network spans the entire Golden State and individuals across the region use the Findhelp platform to find and connect to needed services and support.

23,000 listed programs serving California
9.3 million users
23.1 million searches for resources
117,000 social needs assessments completed

As of October 2025, Findhelp partners with more than 89 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 California on Findhelp platforms, Q1 2021 through Q3 2025. — *Growth in searches in California on Findhelp platforms, Q1 2021 through Q3 2025*

Building a better future for Californians, together

The Northern California Social Care Summit was a powerful reminder that while the policies are complex, the mission is simple: to connect people to the help they need.

The conversation doesn’t end here. To learn more about how Findhelp can support your CalAIM strategy and community, connect with our team.

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Findhelp Acquires Uno Health and Is the First Social Care Platform with Benefit Enrollment

Big news: We’re thrilled to announce that Findhelp has acquired Uno Health, a top-tier digital platform for government benefit enrollment. The goal: make it dramatically easier for people to get the benefits they deserve and help our partners—states, payers, and providers—manage the process more efficiently.

Learn how:

This move creates the first-ever full-stack social care platform.

Findhelp will now provide end-to-end enrollment and redetermination for programs like Medicaid and SNAP.

We’re closing the gap between finding help and getting help, making it easier for people to enroll and stay enrolled.

Benefit eligibility, enrollment, & redetermination made easy

As a digital enrollment platform for government benefits, Uno Health simplifies the end-to-end eligibility, enrollment, and redetermination process for programs like Medicaid, SNAP, TANF, and other key income and employment-based benefits.

With this acquisition, Findhelp is the first social care platform to enable rules-based eligibility assessments, closed-loop referral capabilities, application creation, enrollment submission, and recertification—all in one comprehensive longitudinal record.

All-in-one support: One simple digital process for checking eligibility, applying, and handling renewals for all major income-based programs.
Flexible help: Pick the support level you need, from free, do-it-yourself screeners to a “we’ll handle it” fully-managed service.
Real savings, less hassle: Our digital-first approach slashes administrative costs by up to 75% and boosts document return rates by 3x.
More people get help: Organizations using our tools see 85% or higher approval and renewal rates—nearly double the national average.

“Uno built an incredible technology to simplify this process, including: easy eligibility screenings, an intuitive document upload process, and the ability to seamlessly submit an application. Together, we’re modernizing enrollment and creating a more efficient application process for these benefits.”

Erine Gray

Founder & CEO, Findhelp

Why this, why now?

Enrolling in benefits is difficult. Every year, billions of available dollars go unused because the system is too complex, fragmented, and intimidating. On average, 30% of Americans who are eligible for these programs don’t get enrolled, leaving a staggering $80B on the table annually. People simply get lost in the paperwork.

Add to that new Medicaid community engagement requirements and redetermination policies, which are challenging states, payers, and providers to innovate. To manage these changes, stakeholders need modern solutions that are sustainable and transparent.

We’re directly addressing this national challenge by offering an integrated digital solution to help people check eligibility, apply for benefits, submit documents, and stay enrolled in critical programs. When folks can access the support they qualify for, their health outcomes and economic stability improve.

A “full-stack” solution: What’s included?

Adding these new capabilities to Findhelp’s technology creates the first true full-stack social care platform. It streamlines every step of the journey: eligibility checks, document collection, application submission, and redetermination across 10 core income-based programs.

Here’s a look at what makes our platform so different:

End-to-End Enrollment: Our comprehensive solution manages everything from eligibility checks to application submission and tracking, keeping people informed along the way.
Fast, Digital Experience: The eligibility check takes only 60-90 seconds and provides a clear benefits guide for people to navigate their options.
Intelligent Document Collection: The rules engine knows exactly which documents are required for each application, making it easy for people to submit and attach the necessary info the first time.
Flexible Integrations & Support: The platform works within existing Findhelp workflows, can be used independently, or connected to State Constituent Portals and Eligibility Systems. We offer everything from free self-service screeners to fully outsourced enrollment management.
Better Outcomes: Organizations can achieve 85% or higher approval and redetermination rates and 85-90% enrollment success rates. This is a huge leap from the industry average of 40-50%.
Data-Driven & Compliant: The platform is HITRUST-certified and HIPAA-compliant. It can ingest claims, exemption, and hardship data to streamline applications and reduce administrative burden.

How this helps everyone

Our solution is designed to solve real problems for our partners and customers:

Hospitals & Health Systems

Streamlined enrollment means less uncompensated care, more efficient case management, and greater coverage continuity.

Payers

Improve revenue optimization and risk capture, reduce member churn, and help boost HEDIS and STAR ratings.

Government

Simplify complex eligibility processes, cuts down on incomplete applications, and helps states meet new policy mandates while saving costs.

Connecting the dots: From a referral to real stability

Every day, millions of people use Findhelp to search for support with food, housing, and utilities. A large percentage of those daily referrals are for income-based programs like Medicaid and SNAP. But too often, that’s where the journey gets stuck—a person gets a referral but gets lost in the complex enrollment paperwork.

By embedding benefit enrollment and redetermination workflows directly into the Findhelp ecosystem, we can finally close that gap. The result is a single, unified experience that helps people not only find help but stay connected to it with dignity and ease.

“By joining Findhelp, we’re creating something truly unique… Together, we can tackle the root causes of under-enrollment at a national scale and finally modernize how benefits are accessed and managed.”

Anna de Paula Hanika

Co-Founder, Uno Health

See our benefits enrollment options in action

With a proven platform, thriving network, and tailored solutions, Findhelp is powering the foundation for a better social safety net—schedule your demo today and see for yourself.

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Amplify Your Impact: Become Findhelp Certified

Your organization works tirelessly to support your community. Findhelp is your partner in this mission, connecting people in need to the critical services you provide.

Ready to maximize your program’s reach and showcase your commitment? The Findhelp Certification program is your next step. It’s a professional credential that validates your expertise and boosts your visibility on the nation’s leading social care network.

In this post, you’ll learn how to:

Get Recognized: Earn a free professional credential that validates your expertise in using the Findhelp platform to connect people with social care.

Increase Visibility: Showcase your skills as an individual navigator and boost your programs’ visibility on Findhelp.

Become Navigator Certified: Attend two free virtual trainings and pass a short quiz.

We’re excited to offer two paths to certification, designed to empower both the dedicated individuals working to connect people to resources and the organizations they represent. Certification isn’t just another training—it’s a free tool to help you serve more people, more effectively.

Available Now: Navigator Certification

Getting certified as an individual navigator is easy! This credential highlights your Findhelp expertise to your professional network and shows your dedication to connecting people to the help they need.

Benefits for navigators

You may have seen some of your colleagues sharing their Findhelp Certification and wondered, ‘what’s in it for me?’.

Help people more efficiently. Learn the ins and outs of Findhelp’s free navigation tools so you can connect more people to the right resources in less time.
Showcase your expertise. Highlight your achievement to your colleagues and community by adding the Findhelp Certified credential to your LinkedIn profile and the Findhelp Certified badge to your website, email signature, and more.

Easy as 1-2-3

Your simple path to certification:

Attend the 101 Training: Findhelp Fundamentals

Monthly, 2nd Tuesdays | Register

Learn how to search for and connect people to resources, send and track your referrals, and claim your program to join the findhelp.org network.

Attend the 201 Training: CBO Tools

Monthly, 3rd Tuesdays | Register

Learn how to manage program listings, collaborate with your team, update intake and determine eligibility, and report on your impact.

Pass a Short Knowledge Check

Whenever you’re ready

Test your knowledge with a quick quiz. Answer at least 7 of 10 questions correctly to pass! (If you fail, no worries—you’re welcome to try again).

That’s it! After passing the quiz, you’ll be an official Findhelp Certified Navigator 🎉

We’ll email you the Findhelp Certified badge to add to your website. You’ll also receive a link to add the ‘Findhelp Certified’ credential to your LinkedIn profile, highlighting your expertise and dedication to your professional network.

Get started: Attend the training

Coming Soon: Program Certification

Program Certification is for programs claimed by Certified Navigators. These programs will feature a special certification badge on their Findhelp listings, signaling to those seeking help that your program is a verified and highly-committed resource. Stay tuned!

Benefits for programs

Boost Your Visibility: Certified programs will rank higher in search results on the Findhelp platform, putting your services in front of more people.
Build Trust Instantly: The program certification badge will show users that you are a verified and trusted partner in the network.
Empower Your Team: Equip your staff with expert-level knowledge to make faster, more effective referrals.
Fund Your Work: Highlight your certified status on grant applications to formally recognize your expertise and attract funding.

Example of the certification icon on a program’s Findhelp listing

Get started: Claim your program(s)

While you wait for the launch of Program Certification, take 30 seconds to become a Claimer for your program(s).

Program already claimed? Go ahead and re-claim it so that you’re registered as a Claimer in our system.

Claim your program(s)

Frequently Asked Questions (FAQs)

Who can become certified?
- Anyone who works at a community program listed on Findhelp can get Navigator Certification. Not listed? Add your program for free!
What is the difference between claiming and certification?
- Claiming gives you ownership of your program page and access to our free management tools.
- Certification is a credential that recognizes your platform expertise and commitment to serving the community through Findhelp.
What if I don’t pass the quiz?
- You can try again!
- The quiz can be taken multiple times until you correctly answer at least 7 out of 10 questions.
- If you need a refresher, feel free to attend another training session or join our weekly CBO Office Hours.
What if my program reaches capacity?
- Findhelp’s tools allow you to update and publicly display your program’s availability.
- Indicating that your program is “at capacity” or “has a waitlist” will temporarily lower it in search results
- When you’re ready to accept new clients and update your status to ‘available,’ you’ll return to your boosted search placement.

Learn More

Stay in the loop with Findhelp updates and support:

CBO Office Hours | Every Tuesday from 10:00 to 11:00am Central.
Support Portal | Our knowledge base with how-tos and details about Findhelp’s tools and analytic

Minnesota Social Care Summit: Highlights from the North Star State

Last week we gathered in Minnesota for our Regional Summit—a day dedicated to building stronger connections between healthcare providers, community-based organizations (CBOs), and social care leaders. Together, we explored what it takes to create a more integrated, sustainable network of support for Minnesotans.

Throughout the day, speakers and attendees shared both the challenges and the innovations shaping their work. From addressing behavioral health gaps in rural communities to experimenting with new referral workflows, the summit highlighted the creativity and collaboration driving Minnesota’s social care landscape forward.

In this post, you’ll learn:

How Essentia Health is tackling the behavioral health crisis in rural Minnesota, achieving a 94% closed-loop referral rate

Practical strategies from both a health system and a CBO on using data and process improvements to strengthen their collaborative network

The critical steps Minnesota leaders are taking to address CBO capacity

Highlights from the 2025 Minnesota Social Care Summit

This year’s Summit featured 27 participants from 16 organizations across Minnesota, representing health plans, health care providers, nonprofits, and more.

A sincere thank you to all our speakers and attendees for a day filled with candid conversation and a shared commitment to strengthening the social safety net for every Minnesotan. It’s clear that the spirit of collaboration is strong in the North Star State.

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

A vision for trust and integration

The day began by addressing a foundational element of any connected network: trust. In a discussion about data privacy, participants expressed concern about how they can ensure people’s information is safe.

Findhelp’s coalition model offers one answer. Already in use across eight states, it allows individuals to choose exactly which organizations can view their referrals—contrasting with “all-in” consent models used elsewhere. This approach puts control in the hands of the individual, ensuring privacy while still fostering collaboration among partners.

Closing the loop on behavioral health: Essentia Health’s blueprint

One of the most pressing topics of the day was the significant gap in behavioral health (BH) access, especially across northern and rural Minnesota, where wait times for an appointment can stretch to six months. Our partners at Essentia Health shared their innovative and determined approach to closing this gap.

Facing challenges of long wait times, shifting provider networks, and capacity constraints, Essentia took action.

They built a comprehensive directory on their platform that includes all available BH resources to ensure their care coordinators had a complete view of available services.

Find Help Minnesota, a behavioral health program locator.

Findhelp partnered with the Minnesota Department of Human Services (DHS) to roll out a statewide behavioral health program locator—Find Help Minnesota—enabling organizations to seamlessly coordinate referrals and expand access to critical mental and behavioral health resources.

With more than 3,500 employees placing referrals through their Findhelp platform, Essentia has worked to ensure behavioral health resources are visible and accessible—even in rural and northern Minnesota, where a simple appointment can mean a six-month wait.

Attendees were eager to learn how these workflows played out in practice, asking questions about integrating screeners directly into Epic and managing duplication across systems. The discussion underscored both the complexity and the promise of making behavioral health referrals smarter and more effective.

Essentia Health’s partnership with behavioral health provider Nystrom & Associates, combined with process improvements, boosted their closed-loop referral rate significantly. They went from a 72% rate to a 94% rate—in just one year.

Key successes and takeaways:

Powerful Partnerships: Essentia forged a deep partnership with Nystrom & Associates, a key behavioral health provider.
Impressive Outcomes: Through process improvements and dedicated community engagement, they dramatically increased their closed-loop referral rate on the project from 72% to an 94% in the last year.
A Scalable Model: The success sparked a conversation about packaging Essentia’s curated BH directory as a specialty network—a feature other health systems could simply “toggle on” to provide immediate, comprehensive BH resources to their teams.

Building a collaborative network: Strategies from Fairview Health Services and The Food Group

Our next session focused on the strategies behind building and sustaining strong partnerships, featuring perspectives from both a major health system and a vital CBO.

Fairview Health Services detailed their thoughtful approach to integrating Findhelp. By tailoring workflows to different roles—clinicians, care coordinators, and inpatient/outpatient teams—they’ve created a system that balances efficiency with depth. For example:

Clinicians access priority resource lists that appear on Epic after-visit summaries (including QR codes).
Care coordinators dive deeper into Findhelp searches, supported by screener data that auto-fills resource recommendations.

Social care program accountability

Fairview also emphasized the importance of accountability to drive programmatic success:

Each program they’ve launched includes an evaluation plan and partner surveys.
They established community advisory committees for every hospital service area.

Using Findhelp’s analytics dashboard, Fairview is already tracking referrals, claimed programs, and baseline data to shape their 2026 goals, strategically focusing on building CBO partnerships where the need is greatest.

A core challenge: CBO capacity

A critical theme emerged from this discussion: as health systems get better at screening and referring, how do we support the CBOs now facing increased demand, especially as grants and other funding sources tighten?

The group engaged in a transparent conversation about creative solutions, from Essentia’s model of directly paying CBO partners for their work through an Incentivized Trusted Network to an exciting discussion between Essentia and Fairview about pooling resources to jointly build CBO capacity.

From a CBO perspective, The Food Group shared how they measure success and adapt to growing demand, as healthcare partnerships have doubled their referrals in the past year.

To manage this influx, they analyzed their outreach process. By simply adding a fourth attempt to follow-up with individuals (text, call, call, email), they boosted their connection rate by 15%, ensuring more people received the help they needed.

A more connected future

The day wrapped up with a forward-looking discussion about the tools and features that will continue to power this work:

Two-way texting with CBOs to streamline communication.
Eligibility verification and how integrations could reduce barriers for clients.
Reimbursement models, including the potential of Z Codes, to quantify and sustain social care interventions.
Specialty networks like AIDA’s post-acute care network and the role they might play in expanding access to services.

Beyond the Summit: Our work in Minnesota

Our network spans the entire North Star State and individuals across the region use the Findhelp platform to find and connect to needed services and support.

6,770 listed programs serving Minnesota
950,000 users
2.4 million searches for resources
108,000 social needs assessments completed

As of October 2025, Findhelp partners with more than 16 customers throughout the state. They use our 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.

Growth in searches in Minnesota on Findhelp platforms, Q1 2021 through Q3 2025. — *Growth in searches in Minnesota on Findhelp platforms, Q1 2021 through Q3 2025*

Building a better future for Minnesotans, together

The Minnesota Social Care Summit was a powerful reminder of what’s possible when healthcare systems, community organizations, and technology partners come together. Themes of privacy, accountability, and sustainability ran throughout the day, underscoring the shared responsibility to build a stronger, more connected social care network.

The conversation doesn’t end here; to learn more about how Findhelp can support your work in Minnesota, connect with our team.

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

Connecting residents to the right social services at the right time is a critical challenge facing every growing community. In Denton County, Texas, community-based organizations and government leaders recognized the need for a shared digital infrastructure to connect the public with available services. In response, the City of Denton and Denton County Public Health acted as conveners, funding and facilitating a community-wide solution. Since its launch, the FindHelp Denton County platform has been used by thousands of residents to connect with vital services.

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.

In this post, you’ll learn how:

County and City came together to implement a centralized, community-wide system for connecting residents with social services

This partnership created a methodical approach that included government facilitation, a phased implementation plan, and broad community collaboration

In the first year, 18,000 residents used the platform to connect to resources

The challenge: Binders, sticky notes and spreadsheets

Denton County’s dedicated community-based organizations (CBOs) worked tirelessly to support residents. However, without a shared, centralized system, each organization maintained its own information. For social service professionals, this often meant relying on individual expertise, hefty printed binders, or sticky notes to make referrals—a diligent but decentralized approach.

This structure created systemic issues:

Residents faced a complex landscape with no clear starting point to find help.
CBO staff found it difficult to connect people to services outside their own agency.
The lack of a unified directory with closed-loop capabilities made it challenging to track referral outcomes.
The high cost of referral technology and the need for ongoing technical support placed such a solution outside the reach of most individual organizations.

Denton County and the City of Denton partnered with Findhelp to create a community-wide solution to connect residents to social services.

Located in North Central Texas, Denton County is a fast-growing region that recently surpassed a population of one million. This rapid growth has led to challenges in areas like housing affordability and has shifted the needs of the community. This case study highlights a partnership between two key local government entities: the City of Denton’s Community Services Department and Denton County Public Health. Their shared history, originating from work with the local United Way, fueled a long-standing goal to overhaul the community’s information and referral process.

The community recognized the need for a modern, shared infrastructure, and came together, with support from the City and County, to better connect the entire network of care.

The solution: A unified and methodical approach

Recognizing an opportunity to support community members in efficiently accessing information about services available, the City and County collaborated to support a multisector, foundational infrastructure to support referrals and connectivity to care. Their approach was guided by several key principles:

Government as a facilitator: Local government’s role was to provide a stable, low-cost infrastructure that allowed CBOs of all sizes to easily list their services and efficiently connect with people seeking services.
A deliberate, phased implementation: The team resisted the urge to rush. They understood that a successful launch required a precise, patient process to build trust and ensure utility. They mapped out an 11-week implementation timeline, working closely with Findhelp to ensure the platform would be reliable from day one.
A collaborative community-wide solution: The process was not top-down. The team cast a wide net, engaging over 70 CBOs in pre-launch planning sessions. This ensured the framework for the hub site included direct input from the people who would use it most.

Real world impact: Key strategies for success

With the platform built, the Denton County team employed several key strategies to ensure its successful integration into the community fabric.

Sustainable funding and partner buy-in

The team’s approach went beyond just launching a tool; they deliberately built community-wide solution and the foundation for long-term success:

Strategically used American Rescue Plan Act (ARPA) funds to cover implementation costs, demonstrating a strong government commitment and removing financial barriers for CBOs.
Directly addressed a major CBO pain point by providing a free, efficient alternative to unwieldy clipboards and spreadsheets.
In combination, these choices gave CBOs an immediate and compelling reason to adopt the system for their daily work.

Building a trusted, community-focused brand

Rather than using an official government brand, the team intentionally created a unique and neutral identity: “FindHelp Denton County.”

This unique identity cultivated a sense of community ownership and approachability.
To bring the brand to life, they developed a simple, low-cost, and highly effective marketing tool—a business-card-sized card with a QR code linking to the site.
Printed in English and Spanish, these evergreen cards were easy for partners like libraries, schools, and public health staff to distribute, providing a tangible and accessible entry point to the digital network.

Fostering deep CBO engagement

The team actively works to help CBOs use the platform to its highest potential. This includes:

Training on advanced features like “Favorites Folders,” which CBOs now use to create curated, topic-specific resource lists (e.g., perinatal mental health) that have replaced outdated printed guides.
Promoting the site’s ability to readily translate text and messages into a user’s preferred language, ensuring broader access for the community.

By helping CBOs become platform experts, the team is replacing inefficient workflows and building a more coordinated system of care.

Using data to inform strategy

The team leverages platform analytics to guide outreach and resource allocation, focused on usership trends and topic-specific searches:

A key part of their strategy involves translating this data into actionable insights for partners and leaders.
They provide CBOs with maps visualizing where searches originate, helping them identify geographic hotspots of need and make informed decisions about where to place resources.
This same data is framed in visualizations for elected officials, providing a clear, evidence-based picture of community needs to guide high-level planning and policy.

An award-winning model for other counties

The National Association of County and City Health Officials (NACCHO), the representative body for over 3,300 local health departments nationwide, selected Denton County Public Health as one of the winners of its 2025 Model Practice Awards. This annual program recognizes exceptional local public health initiatives, chosen through a competitive, peer-reviewed process. Denton County was one of 19 local health departments to receive the Model Practices award in 2025.

As a Model Practice Award winner, Denton County Public Health made this short video outlining their strategy and approach to building a community-wide solution. Hosted on NACCHO’s website, the video will serve as guide for other counties who want to replicate Denton’s success.

Measurable results and future vision

These strategies translated directly into significant, measurable outcomes, establishing the platform as the backbone of Denton County’s social care strategy.

Significant Platform Growth: In its first year, the platform was accessed by over 18,000 users who conducted more than an average of 1,440 searches per month. This activity resulted in over 23,000 interactions with program listings on the site.
Positive Community Reception: Community feedback highlights the platform’s alignment with resident needs.
- A 2024 City of Denton survey showed that 90% of respondents were familiar with programs and services offered by nonprofits funded by the City.
- The platform saw immediate positive reception, with a survey conducted just six months after launch showing that 39.5% of respondents chose FindHelp as the tool they were most likely to use.
- This grew into sustained awareness, with the 2024 survey showing that 64% of residents now know about the site and 56% would use a website like FindHelp Denton County to connect someone with resources.
- Community members shared that they like the ability to access resource information in real time from any device.
Data-Driven Insights: Housing is the most significant need, accounting for 54% of all search activity in 2024.
- The top search terms were “Rent” (2,104 searches), “Help Pay for Housing” (495 searches), and “Food Pantry” (363 searches).
- This data aligns with community survey results where providing housing for vulnerable populations was the #1 affordable housing priority.
- The most searches on the platform originate from the city of Denton (7,538 searches) and ZIP Code 76201.
A Thriving and Expanding Network: The platform now lists over 2,400 organizations. In the last year, 220 new programs were added and 163 programs were claimed by CBOs, ensuring information is accurate and up-to-date.

Denton County has successfully laid the groundwork. Their year-two vision is focused on deepening their impact by expanding CBO usership, prioritizing access in asset-limited areas, and enhancing their closed-loop referral network. They are proving that with the right strategy and tools, any community can move from a fragmented system to a resilient, connected network of care.

Bring a new standard of care for your community

Let’s build your community-wide solution together! Findhelp has a history of partnership with county governments to increase efficiency, improve public health, and support their staff and residents. Schedule a conversation with our team to get started.

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New Jersey Social Care Summit: Highlights from the Garden State

Findhelp recently hosted an in-person New Jersey Social Care Summit on the Rutgers University campus with a dynamic group of leaders from community-based organizations (CBOs), healthcare systems, government, and more. The day was filled with insightful conversations about building a more connected social care ecosystem, leveraging technology to meet complex needs, and the power of partnership in creating lasting change across the Garden State.

In this post, you’ll learn:

How leading New Jersey health systems are effectively integrating social needs screenings directly into their EHRs and patient portals.

Creative, community-based strategies for reaching vulnerable populations.

Key lessons from New York’s 1115 Waiver on how to build a scalable infrastructure.

Highlights from the 2025 New Jersey Social Care Summit

This year’s summit featured 37 participants from 21 organizations across New Jersey, representing local and county government, health care, nonprofits, schools, and more.

We want to extend a heartfelt thank you to all our attendees and speakers for sharing their expertise and passion. It’s clear that by working together, we can build a stronger, more accessible social safety net for all New Jerseyans.

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

Our vision for a digitized social safety net

Our keynote session kicked off the day by exploring Findhelp’s vision for a connected, end-to-end social care ecosystem. We reviewed our comprehensive suite of solutions designed to support every step of the social care journey:

Our core platform, connecting people to the services they need in every U.S. ZIP Code.

Findhelp's acquisition of Kiip will enhance its existing CBO technology.

Case management tool, free for CBOs, nonprofits, and their clients.

Explore Findhelp's SchoolCare platform and Medicaid billing solution.

Health record used by school nurses to support student well-being.

Benefits eligibility tool that simplifies finding and applying for state & federal programs

We also shared a glimpse into the future with Personalized Search and Member Verification Workflows, which use data and insights to connect people to the right services more quickly and efficiently.

The impact in New Jersey is clear: with nearly 2 million users and over 2,200 claimed programs in the state, the network is robust and growing. This strong foundation is crucial as the state moves forward with initiatives like the NJ 1115 Waiver, which will leverage Medicaid to address social needs like housing and nutrition through collaboration between managed care organizations (MCOs), health systems, and CBOs.

In practice: How New Jersey’s health systems are integrating social care

Our first panel, “The Power of We,” featured leaders from across the state who shared how they are embedding social care into their clinical workflows. Speakers Christine Young of Englewood Health, Max Kursh of Cooper University Health Care, and Victoria Gregoria and Abby Erasmus of Children’s Specialized Hospital discussed their journey from manual resource lists to integrated, technology-driven solutions.

A common thread was the powerful integration of Findhelp with Epic, their electronic health record (EHR). This has enabled them to seamlessly screen patients for social determinants of health (SDoH).

Key successes:

Leveraging MyChart: Both Englewood and Cooper Health have seen huge success by embedding SDoH screenings and a self-search tool directly into MyChart. This gives patients a private and convenient way to disclose their needs and find help. Max from Cooper Health called it their “biggest bang for the buck.”
Staff Adoption: Children’s Specialized has seen incredible buy-in from clinicians and nurses, who are excited to have an effective tool to support their families. By listening to their staff, they made the platform an essential part of their workflow.
Data-Informed Services: Using screening data, Children’s Specialized identified food insecurity as a major need and established food pantries at their facilities, serving about 4,000 patients a year.
Supporting the Supporters: In a poignant moment, Vikki from Children’s Specialized shared how they discovered staff members were also facing social needs but were hesitant to ask for help. This led them to create a separate, confidential Findhelp site just for their employees

Community at the core: Innovative approaches to engagement

Our second panel, “A Simplified Approach to Meeting New Jersey Requirements,” highlighted how organizations are using technology and community engagement to reach people where they are. Morgan Newcomb from Family Health Initiatives, Diana Belle and Selina Holmes from Choose Healthy Life, and Austen Williams from The Medi showcased their unique and effective strategies.

Connection stories:

Family Health Initiatives (FHI): FHI integrated Findhelp’s network into their CNJLink case management platform via an API. This move doubled their referral numbers and increased their closed-loop referral rate.
Choose Healthy Life (CHL): Operating out of trusted community pillars—churches—CHL’s Health Navigators meet people in familiar settings like food pantries to conduct screenings and connect them to resources. Diana shared how their Findhelp site has become her team’s personal “rolodex” for vetted, reliable programs.
The Medi: To support New Jersey’s ALICE (Asset Limited, Income Constrained, Employed) population, The Medi partnered with employers to offer Findhelp as a confidential resource. Austen emphasized that “technology without people is useless,” detailing their grassroots outreach with posters in break rooms and QR codes in libraries to ensure people knew help was available without having to ask.

Lessons from New York’s 1115 waivers: Paving the way for sustainable social care

Looking at a large-scale model of social care in action, we welcomed Indiana Lopez and Katherine Morillo from SOMOS Community Care, a physician-led health system in New York, to close out the customer-led sessions at the 2025 New Jersey Social Care Summit. They shared their experience leading social care efforts for the NY 1115 Waiver in the Bronx, with the ambitious goal of screening all 800,000 Medicaid members.

SOMOS Community Care explained how Findhelp serves as their central hub for the entire waiver workflow—from screening and eligibility assessments to referrals, service delivery, and even invoicing and claims reimbursement.

Their journey underscored the vital role technology plays in managing complex, large-scale initiatives. As Indiana, a physician herself, noted, “IT and data is the foundation for accountability.” Their success hinges on strong CBO partnerships, a flexible approach, and keeping processes simple for everyone involved. Indiana and Katherine highlighted how Findhelp technology bridges the gap between healthcare providers and community-based organizations to create a more resilient, flexible, and integrated social care system.

Simplify waiver implementation

Beyond the Summit: Our work in New Jersey

Our network spans the entire Garden State and individuals across the region use the Findhelp platform to find and connect to needed services and support.

8,008+ listed programs serving New Jersey
1.9 million users
5.2 million searches for resources
55,400+ social needs assessments completed

As of September 2025, Findhelp partners with more than 28 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 Jersey on Findhelp platforms, Q1 2021 through Q3 2025*

Building the future, together

The day wrapped up with a look at our product roadmap, where we reaffirmed our commitment to building the infrastructure for a unified social care network. By providing CBOs free tools like Kiip and prioritizing interoperability, we aim to create a single source of truth that allows all sectors to work together seamlessly.

The discussions at the New Jersey Social Care Summit were a powerful reminder of the incredible work being done across the state. The path forward is built on the partnerships, innovations, and shared dedication we witnessed throughout the day.

The conversation doesn’t end here. To learn more about how Findhelp can support your work in New Jersey and beyond, connect with our team.

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Our Pricing Philosophy: Consistent and Transparent

When organizations buy software, pricing is often the most frustrating part of the process. Hidden fees, confusing licenses, and endless negotiations have become the norm. But when the work is about helping people—feeding families, connecting them to housing, or providing access to care—pricing shouldn’t be a game. Findhelp’s pricing philosophy is different: We’re committed to fair and transparent pricing.

In this post, you’ll learn how:

We reject hidden fees and complex contracts by publishing all prices directly on our website

We ensure access for all budgets through simple, affordable subscription fees

By prioritizing trust, we can ensure money is spent on helping people, not on inflated technology costs

Why pricing matters in social care technology

At Findhelp, we believe pricing should be straightforward, transparent, and fair. No nickel-and-dimeing. No seat licenses. No hidden fees. Just clarity about what you get, what it costs, and why we price the way we do.

We built this philosophy not as a marketing tactic, but because of lived experience. We spent years inside government programs, watching inefficient systems waste money that could have gone directly to communities.

We are people-first. That principle guides how we serve our customers and how we set our prices.

The challenges with technology procurement

To understand our pricing philosophy, it helps to know where we came from. Our founder worked on a large government project. The goal was noble: make it easier for Texans to apply for benefits like Medicaid, SNAP, TANF, and CHIP using technology. The promise was simple: a single integrated application process.

The reality was different.

Massive contracts, some worth hundreds of millions of dollars, were awarded to large consulting firms. Armies of consultants filled offices, billing hourly rates that soared past $200 or more. These firms then subcontracted to smaller firms, who subcontracted again.

The project eventually collapsed, consultants left, and teams scrambled to rebuild. Meanwhile, people who needed food or health insurance waited in long lines or on hold for hours.

The way companies price technology creates challenges

Opacity: Contracts are long and complicated, with rates buried in fine print. Customers don’t always know exactly what they are paying for until several invoices pile up.
Inefficiency: Layers of subcontractors with inflated costs slow down delivery. Dollars are wasted instead of serving people.
Mistrust: When governments and other large organizations spend millions without getting results, organizations working to solve problems for their communities and the people themselves stop believing in the system.

‘People-first’ pricing principles

This experience of watching inefficiencies undermine critical public programs created a conviction: Technology companies serving government, healthcare, and social care must be people-first. That is why we made a commitment: Our pricing practices will set a new industry standard.

When Findhelp was founded, it wasn’t just a technology company. It was an attempt to build a different kind of partner for the organizations we serve.

We asked ourselves: If we are people-first, how should we price our work?

The answer was clear:

Transparent, so anyone can see what it costs.
Fair, so customers know they are paying for value, not padding.
Mission-driven, so government, health care organizations, and community-based organizations can afford the tools they need.

We knew this approach might not always maximize revenue, but it would maximize trust. And, trust is worth more than a bloated contract. So, we solidified our pricing philosophy around those three core principles:

Transparent pricing

We believe software pricing should be as clear as buying a t-shirt or a streaming subscription. That’s why in 2017, we became the first company in our space to publish pricing on our website. You don’t need to sit through demos to get a ballpark figure. What you see is what you get. Transparency is not only the fair thing to do, it’s also efficient. Customers spend less time negotiating and more time serving people.

K-12 school districts

All other sectors

Fair and reasonable pricing

Findhelp.org, the nation’s largest social network, is always free to the public. Anyone can search for food, housing, transportation, or other support without cost. That principle will never change.

For organizations that employ social workers, care managers, or community health workers, we offer flexible subscription models with advanced features. Customers can upgrade or downgrade depending on their needs.

When custom work or training is required, we charge a single transparent hourly rate. No inflated consulting contracts. No surprise fees.

Mission-driven pricing

Our infrastructure is already built, covering all 50 states. That means we don’t need to inflate prices to cover overhead. We believe customers trying to help their patients, members, residents, or clients should always be able to afford the tools they need to serve their communities, despite operating under tight budgets.

At Findhelp, we commit to being good stewards of every dollar you spend with us. We will never exploit complexity or urgency to inflate costs. We will never tell you we are the only vendor who can do this work. Competition is healthy and customers deserve choice. Our fair and transparent pricing is the model of what ethical technology partnerships should look like.

We also believe that pricing reflects values. If our customers are paying inflated technology costs, that money comes from somewhere: from government budgets, from hospital margins, from community grants. Every unnecessary dollar spent on technology is a dollar that isn’t used for its intended purpose: helping people.

A partner you can trust

The world of government and health care technology is complicated. The needs are urgent and the budgets are tight. But one thing should not be complicated: Pricing.

At Findhelp we are people-first. That means we put transparency, fairness, and mission at the heart of everything we do—including our pricing.

We know our customers face hard decisions every day. We want to make at least one of those decisions easier: choosing a technology partner you can trust.

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Watch | How Trinity Health Reduced Preventable Hospitalizations by 16%

In the modern healthcare landscape, it’s increasingly clear that the majority of health-related activities happen outside the doctor’s office. Factors like access to food, housing, and social support—health-related social needs (HRSN)—can have a greater impact on well-being than clinical care alone. In a recent webinar with Becker’s Healthcare, Maureen Pike from Trinity Health and Carla Nelson from Findhelp discussed how embracing this reality helped Trinity Health achieve a 16% drop in preventable hospitalizations for its most vulnerable patients.

In this post, you’ll learn how:

Trinity Health embedded Community Health Workers (CHWs) directly into its clinical care teams to bridge the gap between healthcare and a patient’s daily life.

The program focused on reducing preventable hospitalizations, specifically for high-cost, high-need patients dually enrolled in Medicare and Medicaid.

Trinity integrated Findhelp into Epic, their electronic health record, to streamline referrals and navigation.

This initiative led to a 16% reduction in preventable hospitalizations for the target population.

The challenge: Preventable hospitalizations

Trinity Health focused on preventable hospitalizations—admissions for conditions like heart failure or diabetes that could have been managed in an outpatient setting—as a key metric. They discovered that patients dually enrolled in Medicare and Medicaid, had an avoidable hospitalization rate more than double that of the general population.

Trinity Health reduced preventable hospitalizations by integration social care (Findhelp and community health workers) with clinical care.

“Within this clinically integrated network, we have to look at patients’ social needs and their social circumstances and how that is affecting care plans, to be able to have their basic needs met every day… It’s not only in the value-based environment, but there’s definitely a great case for it when you’re trying to really comprehensively serve a patient and you’ve got a business model where expenses can be justified by their impact on the eventual outcome and eventual total cost of care.”

Maureen Pike, MPH, MBA, RN

Director, Clinical and Social Care Integration at Trinity Health

The strategy: Integrating social care into clinical teams

Trinity Health integrated social care directly into its care model. To address their preventable hospitalizations disparity, the system invested in an internal workforce of Community Health Workers (CHWs):

These individuals are trained laypeople who act as a vital link between the health system and the community.
They are part of the clinical care team, documenting in the EHR and communicating securely, but they also connect with patients in their homes and communities.
This dual role allows them to bridge the gap between clinical needs and real-life social barriers.

“There are many ways at Trinity Health where we have formally integrated community health workers into care teams, as well as social needs screening. Even before it was a requirement from accrediting bodies or a regulatory requirement. We have institutionalized and systematized social needs screening so that we can identify those patients who have needs, and then have a workforce in place that is best suited to be working with those patients… the community health workers are a really important investment.”

Maureen Pike, MPH, MBA, RN

Director, Clinical and Social Care Integration at Trinity Health

Empowering staff with the right tools

To maximize the CHWs’ impact, Trinity Health provided them with a powerful tool: the Findhelp platform. This online network of community resources helps patients and providers find up-to-date, free, or low-cost social services by need and ZIP code.

“[Binders and pamphlets are] hard to keep up to date. And as people move on from their roles or we know there’s a big wave of retirements coming for health care professionals, that knowledge leaves with that person when you’re just counting on what’s in people’s brains or, what’s in the binder, over at the nurses’ station. But Findhelp takes all of that knowledge out of people’s brains and puts it in a searchable place, and this has been helpful on several levels. One, you know, we love to systematize. We love to scale at Trinity Health. This is scalable. This is something that can be and is available throughout our entire system. It’s integrated into our EHR.”

Maureen Pike, MPH, MBA, RN

Director, Clinical and Social Care Integration at Trinity Health

Findhelp’s integration with Trinity’s Epic EHR streamlines the referral process. When a patient’s social needs are identified during a screening, a care team member can immediately pull up a list of relevant resources and add them directly to the patient’s after-visit summary. This approach not only supports the CHWs but also enables patients to self-navigate, broadening the program’s reach.

The results: 16% decrease in preventable hospitalizations

The success of this integrated approach is visible in both the data and individual patient stories. In a four-year analysis, from July 2021 to July 2024, Trinity Health achieved a 16% decrease in preventable hospitalizations for dually-enrolled patients and a 45% reduction in health disparities between duals and the overall patient population.

Success in South Bend

Select Health and St. Joseph Health System, part of Trinity’s accountable care organization (ACO) in South Bend, Indiana, saw extraordinary results during the same four-year period:

The preventable hospitalization rate decreased 41% for duals and 15% for the overall patient population.

Health disparities for duals decreased by 58%.

One patient’s story: The impact of CHWs

The numbers are brought to life by stories like that of Miguel, a 49-year-old Trinity Health patient with heart failure.

Overwhelmed and living alone, he was referred to a CHW who visited his home.
The CHW provided him with simple tools like a scale and a pillbox.
They also connected Miguel to more advanced services like heart-healthy meal delivery and housekeeping services.
As a result, Miguel’s missed appointments dropped by 90%. He also enrolled in cardiac rehab and nutrition classes, regaining control of his health.

Watch: Trinity Health’s strategy & lessons learned

In a webinar with Becker’s Healthcare, Maureen Pike (Trinity Health’s Director of Social & Clinical Care Integration) and Carla Nelson (Findhelp’s Sr. Director of Healthcare and Public Policy) discussed key insights from Trinity’s approach to reducing preventable hospitalizations and health disparities:

How to scale CHW integration across multidisciplinary care teams
How to align clinical and social care with the right tools
How social care platforms helped streamline referrals and close gaps

The Road Ahead

While Trinity Health has seen significant success, the work isn’t without its challenges. Funding the CHW workforce and integrating their efforts seamlessly with existing clinical workflows remain key hurdles. The system is also working to navigate the complexities of billing for CHW services to ensure the program’s long-term sustainability.

For other healthcare organizations looking to replicate this success, the advice is simple: don’t put CHWs in a silo. By intentionally integrating them into the care team and leveraging technology to empower their work, health systems can address the full spectrum of patient needs. Make a measurable impact on health outcomes while lowering cost of care with Findhelp.

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Power seamless post-acute care transitions

Costly, inefficient post-acute referrals & prolonged hospital stays

Unlock efficiency and reduce length of stay

Drive positive outcomes: Organizational benefits

Watch: Findhelp + AIDA in action

Partnering for Better Care Transitions

Is Findhelp + AIDA right for you?

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Ready to modernize your social care workflows?

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Highlights from the 2025 California Social Care Summit

Our vision for a connected California

From the ground up: Sutter Health’s patient-centered pilot

Key successes and takeaways:

From policy to practice: Navigating CalAIM and CBO partnerships

Key themes:

Community organization spotlight: Local partners leading social care innovation

Key themes:

Powering a smarter, more connected safety net

Beyond the Summit: Our work in California

Building a better future for Californians, together

Benefit eligibility, enrollment, & redetermination made easy

Why this, why now?

A “full-stack” solution: What’s included?

Here’s a look at what makes our platform so different:

How this helps everyone

Connecting the dots: From a referral to real stability

See our benefits enrollment options in action

Available Now: Navigator Certification

Benefits for navigators

Easy as 1-2-3

Get started: Attend the training

Coming Soon: Program Certification

Benefits for programs

Get started: Claim your program(s)

Frequently Asked Questions (FAQs)

Learn More

Highlights from the 2025 Minnesota Social Care Summit

A vision for trust and integration

Closing the loop on behavioral health: Essentia Health’s blueprint

Key successes and takeaways:

Building a collaborative network: Strategies from Fairview Health Services and The Food Group

Social care program accountability

A core challenge: CBO capacity

A more connected future

Beyond the Summit: Our work in Minnesota

Building a better future for Minnesotans, together

The challenge: Binders, sticky notes and spreadsheets

This structure created systemic issues:

The solution: A unified and methodical approach

Real world impact: Key strategies for success

Sustainable funding and partner buy-in

Building a trusted, community-focused brand

Fostering deep CBO engagement

Using data to inform strategy

An award-winning model for other counties

Measurable results and future vision

Bring a new standard of care for your community

Highlights from the 2025 New Jersey Social Care Summit

Our vision for a digitized social safety net

In practice: How New Jersey’s health systems are integrating social care

Key successes:

Community at the core: Innovative approaches to engagement

Connection stories:

Lessons from New York’s 1115 waivers: Paving the way for sustainable social care

Beyond the Summit: Our work in New Jersey

Building the future, together

Why pricing matters in social care technology

The challenges with technology procurement

The way companies price technology creates challenges

‘People-first’ pricing principles

Transparent pricing

Fair and reasonable pricing

Mission-driven pricing

A partner you can trust

The challenge: Preventable hospitalizations

The strategy: Integrating social care into clinical teams

Empowering staff with the right tools

The results: 16% decrease in preventable hospitalizations

Success in South Bend