Coordinated Community Networks are digital platforms that integrate healthcare providers, community-based organizations, and social services to systematically address patients’ social determinants of health and improve outcomes. These digital solutions connect healthcare providers with community-based organizations and social services to deliver whole-person care, integrating screening, referrals, and analytics to reduce disparities and avoidable utilization.
Coordinated community networks framework
Community resource referral platforms | Solutions that help connect clients with community-based organizations (CBOs) and other resources, track their progress, and link information back to the clinical care team. These platforms enable standardized screening, resource matching, and closed-loop referral management. Example companies: Unite Us, WellSky, findhelp |
Social determinants of health analytics | Predictive analytics solutions that help surface at-risk clients for immediate referral and social need management options. These platforms analyze patterns in social determinants data to identify high-risk populations and inform intervention strategies. Example companies: Socially Determined, N1 Health, Activate Care, Unite Us |
Equity-based decision support | Solutions that deliver integrated insights in real-time during care delivery to connect patients with appropriate social determinants of health resources at the point of care. Example companies: TruLite Health, Alvee |
Population health analytics | Comprehensive platforms that enable data acquisition, risk stratification, and predictive modeling to understand community needs and measure program impact at scale. Example companies: Datavant, Arcadia, Innovaccer, Lightbeam Health Solutions |
The case for coordinated community networks
Healthcare organizations are struggling to address the growing crisis of unmet social needs that drive poor health outcomes and rising costs. While many health systems recognize the importance of connecting patients to community resources, manual screening processes, fragmented referral systems, and lack of outcome tracking make it impossible to scale these efforts effectively. Without digital solutions to coordinate care across healthcare and social service providers, organizations cannot systematically identify needs, manage community partnerships, or demonstrate the impact of social care programs. Coordinated community network platforms offer a transformative approach to build and manage high-performing networks of community resources that can measurably improve outcomes.
Reduce disparities through systematic social care
Scale community networks and partnerships
Drive data-informed population health impact
Sources
- https://pmc.ncbi.nlm.nih.gov/articles/PMC8540163/,
https://www.socialworktoday.com/news/dn_051214.shtml,
https://pmc.ncbi.nlm.nih.gov/articles/PMC8131473/#:~:text=Food%20insecurity%20and%20housing%20instability,health%20care%20providers%20and%20policymakers.,
https://pmc.ncbi.nlm.nih.gov/articles/PMC7370319/#:~:text=Drawing%20on%20previous%20adherence%20research,nonadherent%20to%20their%20prescribed%20medications. - https://www.ajmc.com/view/edbased-care-coordination-reduces-costs-for-frequent-ed-users,
https://wellsky.com/wp-content/uploads/2022/02/WS-CSWP001-Partnerships-between-CoCProviders-Web-1.pdf - https://cdn.bfldr.com/C0F7NWER/as/g4mnhsw6ghrbwr7jq9ckg9kk/Unite_Us_2022_Impact_Report
- https://pmc.ncbi.nlm.nih.gov/articles/PMC11639679/#abstract1
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- https://www.healthcatalyst.com/learn/insights/top-7-healthcare-outcome-measures#:~:text=The%20healthcare%20industry%20is%20riddled,essentials%20for%20successful%20outcomes%20measurement.
