Access services, track, and report on referral outcomes
The SRN allows users to make “closed loop” referrals. Case Managers, other front line workers, and residents in need of services use the program to identify needed services and enroll in them.
Smart Referral Network programs
For disaster relief, utility bill and rent assistance, MediCal programs
Target Population Specific
Mental Health and Substance Use Disorders, Community Schools, People Experiencing Homelessness
Partners run reports on the Social Determinants of Health outcomes of services, referrals made and received, and referrals that result in services.
Available Live Training and Technical Assistance:
Referral Workflow, Care Management, Data Collection, Integration, Analysis and Consent:
Design referral and care management workflows that support receiving, analyzing, and sharing client information while reducing administrative burden and errors.
Provide consultation on sending referrals to community benefit organizations for client enrollment in services.
Offer strategic support for data collection, exchange, management, and utilization. Support reporting of bi-directional closed-loop referral information and social determinants of health (SDOH) analytics to improve client level outcomes and population health management.
Support better connections for clients to access care, improving health outcomes, and care coordination effectiveness between cross functional community benefit organizations.
Support the development of cross database data integration tools and systems
Support with the collection of client consent and compliance with consent policies
Training Learning Objectives:
- Gain knowledge in creating actionable workflow plans to make, receive, follow up and respond to referrals.
- Learn how to determine service needs for clients from local programs for which they are eligible, obtain client consent, and submit electronic referrals.
- Learn how to utilize chat bot self-enrollment tool that supports clients themselves to identify services and self-refer.
- Understand how to collaborate more effectively with local community benefit organizations on care plans.
- Learn how to document client interactions and manage cases and case files through the SRN.
- Understand how to document client referral and SDOH outcomes, analyze data, and leverage it to access clients to services and improve client SDOH outcomes.
Asset Building & Access to Community Services
Basic Needs/Domestic Violence
Counseling and Youth
Early Care and Education
Immediate Needs (food, shelter, rent, utilities)
Salvation Army (Salinas & Monterey Corps)
Community Human Services (CHS)
* - Only Makes Referrals
** - Received referrals from precluded groups
Making A Difference Together
Chris Torre’s story reflects the power of collective impact and how a community working together can make a difference in a family’s life. Mr. Torre, a single father with three children, found himself homeless after a series of unfortunate events. As is often the case, homelessness was not the only problem. The family also experienced unemployment, lack of child care, and food and transportation barriers.
Several agencies within the Active Referral Network (ARN), a collaborative administered and managed by UWMC, helped the Torre family get back on their feet. As a first step, Mr. Torre was referred to a Prosperity Planner with Goodwill Central Coast, who helped him find shelter and employment. Meanwhile, Castro Plaza Family Resource Center worked with the North Monterey County Unified School District to arrange child care and access to transportation. The Housing Resource Center helped the family move to a new home and provided them with beds and furniture. Additionally, the children were given new school supplies from UWMC’s Stuff the Bus program.
“Along the way I have met some of the most humble people, who always went above and beyond their job descriptions. United Way Monterey County and Castroville Family Resource Center treated me and my kids like family. Thank you for all you guys do. I’ll forever be grateful” —Chris Torre
The Torre family is now in a permanent home and the children are attending school and thriving. They are grateful for the support provided by United Way and its partners and recognize the value of having a robust community network to rely on to ensure that they remain on their path to financial stability.
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"The results of our collaborative efforts mean we have increased capacity within workflows to navigate referrals and coordinate care as well as to document, use, and share SDOH outcomes. Provider teams are better able to make care decisions for individuals, and our community leaders are better able to design broader population health strategies using aggregate data. Individuals in our community with the most significant complexities are benefiting from this partnership."
Chief Executive Officer
Central California Alliance for Health