From Data to Impact: Making CIEs Work for People

PROBLEM:
Clinics know patients can’t be healthy without access to food, but staff don’t have time to stay updated on local food resources or make direct referrals.

SOLUTION:
When a patient completes an SDOH screener in the EMR and reports food insecurity, they can opt to be automatically referred to the Social Navigators in CIE #1 who then book a food bank appointment.

COMMUNITY BENEFITS:

• Clinic staff stay within their existing workflows and software
• Food banks fill appointments that might have otherwise gone unused
• Community members arrive with paperwork already started, reducing administrative burdens

PROBLEM:
Child Services often identifies families with needs beyond their scope but lacks resources to follow up.

SOLUTION:
Child Services securely uploads a simple spreadsheet of families into CIE #2, referring them to Social Navigators.

COMMUNITY BENEFITS:

• Child Services uses a low-tech solution that fits their capacity
• Social Navigators connect with families who may have been overlooked
• Community members receive proactive outreach and support

PROBLEM:
Small agencies lack the funding and expertise to build complex digital referral systems.

SOLUTION:
By joining the CIE #3, even the smallest organizations gain access to free referral management tools.

COMMUNITY BENEFITS:

• Small CBOs receive enterprise-grade tools at no cost
• The Coordinating Entity secures discounted software through group licensing
• More agencies can participate in coordinated care

PROBLEM:
Community members needing utility assistance are often overwhelmed by multiple programs and unclear eligibility rules.

SOLUTION:
The CIE #4 hub allows agencies to set their own eligibility and referral preferences, which feed into a single screening tool. Community members answer a few questions and are instantly matched to the most appropriate resources.

COMMUNITY BENEFITS:

• One form screens for hundreds of programs
• Agencies maintain control over their referral preferences
• Coordinators gain insight into service demand and access gaps

PROBLEM:
Community members must repeatedly fill out the same forms when referred between organizations.

SOLUTION:
CIE #5’s hub enables a network of community-based organizations to refer individuals to one another, using shared intake information.

COMMUNITY BENEFITS:

• Fewer dead ends and less form duplication for community members
• Stronger collaboration and trust among local CBOs
• More seamless and coordinated care delivery

PROBLEM:
Some services—like transportation for food access—have usage limits, which are hard to monitor manually.

SOLUTION:
CIE #6 tracks food transportation rides as “interventions,” making usage transparent.

COMMUNITY BENEFITS:

• Social Navigators can monitor and manage program usage equitably
• Funders receive clear data on service impact and reach
• Finite resources are distributed more effectively

PROBLEM:
Large agencies worry that joining a CIE means scrapping or overhauling their existing tech systems.

SOLUTION:
CIE #7 hub enables seamless data exchange by converting formats behind the scenes, allowing agencies to keep using their own platforms.

COMMUNITY BENEFITS:

• Referring providers stay in their EMR, while food banks continue using their software
• No one has to purchase or learn new software
• Systems work together without disruption to workflows