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Readers Write: Connected Communities and Social Care in the US

October 30, 2019 Readers Write No Comments

Connected Communities and Social Care in the US
By Jaffer Traish

Jaffer Traish is VP of partnerships at Aunt Bertha of Austin, TX.


I’ve been on the road for more than 100 days this year. I’ve been visiting with payers, healthcare systems, colleges, housing organizations, nonprofits, students, patients, and seniors. I’ve also visited EHR companies, population health vendors, and data scientists. The discussion has been focused on learning how to strengthen communities and reduce poverty through connections to social care programs, leveraging collaborative investment and integrated technology.

There is significant alignment among the broad stakeholders in the principles to govern solutions.


  • We describe all people in need as seekers. The entry point where we express needs may be in healthcare, at college, after corrections release, or when we’ve become widowed. The seeker is always at the center — not the referring hospital, payer, or other business interests.
  • Seekers may receive help, though they deserve and desire the dignity of self-navigation. Make it possible to self-refer, and never hide available resources in the long tail of programs nationwide.
  • Seekers own their social care data. This is a tough one, though we have the chance to get it right in social care. Seekers should control how their self-referrals are shared among the network.

Community Organizations

  • Community organizations are able to maintain an unbiased ability to serve people. Do not subject them to industry specific contracts, forced services, or quid pro quo funding.
  • Community organizations should have tools that facilitate relevant intake data and processes respecting privacy rules, whether FERPA, HIPAA, HUD, or others.
  • Community organizations should be more easily able to align with philanthropy in demonstrating service success.
  • Each community is unique. Conversations about solutions should take place in the community, with the community.


  1. Helpers or navigators, the folks who facilitate referrals, go beyond industry (or clinical) staff. Librarians, guidance counselors, and family members are all part of the helper community. This reach of helpers serves the seekers best.
  2. Helpers should be able to act as the legal proxy, with permission.
  3. Helper information should be protected in the referral process. It’s not always appropriate to share the referrer’s name to the seeker.

With this perspective, creative developers can better build integrated, interoperable technology to serve seekers.

For those of us who have spent time in healthcare, we remember when electronic orders brought ambulatory EHRs to life in the mid-1990s. Similarly, eligibility-driven social care connections will bring a nationwide network to life. While we absolutely need policy changes to support equity and opportunity, there is much we can do today.

Executives ask for a multi-year framework to be successful with social care connections and referrals. An example is below.

  • Stage 1: Electronic resource library with breadth and depth available to helpers and seekers.
  • Stage 2: Helper organization promotes self-navigation through their portal.
  • Stage 3: Helpers share program resources with seekers electronically.
  • Stage 4: Helpers share program resource referrals with seekers and CBOs electronically.
  • Stage 5: Helper organization integrates staff workflow within the system of record (EHR, care platform, housing platform, corrections) including data acquisition for business intelligence reporting.
  • Stage 6: Helper organization builds partnerships with CBOs to affect supply of help available.
  • Stage 7: Helper organization funds CBOs, and helpers directly order solutions for social needs.
  • Stage 8: Helper organization participates in interoperability of social care data.
  • Stage 9: Helper organization leverages predictive methods for identifying and helping seekers.
  • Stage 10: Helper organization completes real-time self-navigation risk intervention.

Organizations like the Winn Corporation in housing, Atrium in healthcare, Red Cross and AARP as networks, Cigna as a payer, State of Colorado in government are all exploring these frameworks to build connected communities.

Community organizations also ask for frameworks, such as the one below.

  • Stage 1: Respond to or track assistance.
  • Stage 2: Leverage network tools to participate in data sharing.
  • Stage 3: Leverage reporting for funders.
  • Stage 4: Integrate tracking into preferred case tools
  • Stage 5: Leverage funding donations from helper organizations and broader philanthropy.

I am excited to thoughtfully continue to grow the social care network keeping the seeker at the center, bringing dignity and ease to the process of finding help.

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