We are determined to keep participant experience and agency at the forefront of our work, and neither Closing the Loop nor the future CIE will be successful without effective community engagement. Through Closing the Loop, we have created a User Experience & Engagement committee dedicated to reviewing the closed loop referral process to identify areas of improvement, as well as developing a community engagement plan to bring community voice into governance and decision making. We want to use patients’ and participants’ knowledge, skills and lived experiences to build an intuitive health and social services system, and that begins by hearing directly from community members.
United Way for Southeastern Michigan and its partners are working to develop infrastructure that enables organizations, agencies and sectors to share information and coordinate care planning that creates better experiences for people accessing services. Our efforts to develop this infrastructure, referred to as a Community Information Exchange (CIE), center on the recognition that the health and social services sector lacks the capacity, resources and technology required to work with clients and individuals across organizations and different programs. Even though each sector and agency may work well individually, they are part of a greater system that is disjointed and complex for both community members and for agencies, a system that lacks deep coordination and shared care planning and that is better set up to react to current situations that plan for future care.
What we and our partners are trying to do is build an infrastructure that knits the health and social services system together in a way that works better for people, and we are doing so by following the best practice model laid out by 2-1-1 San Diego’s CIE. At its core, a CIE is a network of partners in the health and social services sectors who have partnered together to coordinate care for persons in need of assistance, committed to a collective approach to care and to work better together in service of the community. A CIE helps partners communicate with one another and contribute information to a shared care plan. It supports proactive care planning by enabling partners to share individual demographic and program enrollment information, get notified of significant events and helps provide organizations a better understanding of the ecosystem they’re operating in. But at the end of the day, a CIE helps to create a better experience for community members.
One of our first forays into closed loop referrals, a significant component of a CIE, is the Closing the Loop project. With his project, we hope to learn what it means to develop a network of partners, a governance structure that incorporates community voice, how to integrate systems and change workflows to support closed loop referrals and how to share care planning duties across systems.
Closing the Loop is a project to improve food security by exchanging data between healthcare systems, local information and referral services, and emergency food system partners to help people access services and let providers know when a person’s food needs have been met. This closed loop referral process ensures providers and other point-of-service team members have the tools necessary to share care management responsibilities and outcome data across organizations. Partners are able to make referrals and share electronic status updates through a secured data hub, and patients are able to engage with a United Way Social Navigator, who provides more individualized support, facilitates access to other needed resources and helps complete the closed loop referral process.
Our partners in this project include Henry Ford Health, Gleaners Community Food Bank, Fish & Loaves Food Pantry, the Detroit Area Agency on Aging, the Southeast Michigan Senior Regional Collaborative and technology consultant Brightstreet Group, LLC. The referral process begins at one of three Henry Ford Health locations in Downriver where a clinician screens patients for food insecurity. If a patient self-identifies as being food insecure, they are offered a referral to United Way’s team of Social Navigators to assist with meeting their needs. If the patient consents, a referral is sent to the Social Navigators who then call the patient to set up an appointment at Fish & Loaves, assist in applying for MiBridges state benefits or MEAP utility assistance, secure a ride to the food pantry, as well as offer traditional information and referral services. Once the appointment is set, volunteers at Fish & Loaves call the patient to remind them of the appointment. After the patient picks up their food, Fish & Loaves documents this encounter and that information is sent back to Henry Ford Health to let providers know their patient’s food needs were met.
United Way for Southeastern Michigan is seeking partnerships with grassroots and community-based organizations to conduct qualitative, in-depth interviews with community members (including service beneficiaries) living in Wayne County. These interviews will help us learn from those in the community who have first-hand experience navigating and accessing resources in the health and social services sector.
Purpose: The interviews will help us to understand and incorporate the experiences of community members as they navigate resources, consent to receive services and share personal information. Our goal is for these interviews to act as the foundation for long-term relationship building and engagement, rather than one-time transactional outreach. Ultimately, we are looking to learn from community members how they want to participate in decision making and be engaged in a future CIE.
Topics of discussion during the community engagement interview include:
Decision Making and Governance
Technology and Data Sharing
Organizations may apply to interview 50 people or less. For organizations applying to interview 50 people, we anticipate the capacity to conduct up to 130 hours of work. Organizations planning to conduct less than 50 interviews will require less hours of work. These estimates are based on the following activities:
Organizations will have up to 3 months to complete this work. Based on submissions received, we will either award one organization or a combination of organizations to reach up to 50 interviews total. The award amount will include compensation for community member interviews; the compensation for each interview must be $50/hr.
Block clubs, faith-based organizations, educational institutions, nonprofit and social service organizations
Proposals should be submitted via email as attachments, in Word or PDF format. The proposals should include the following components:
Aug. 1: The RFP will be posted publicly.
Aug. 1 to Aug. 8: Question period. Respondents are invited to submit questions to email@example.com.
Aug. 10: Responses to questions will be sent to all respondents.
Aug. 15: RFPs due by email by 5:00 EST to firstname.lastname@example.org.
Aug. 29: United Way for Southeastern Michigan notifies respondents.
Sept. 12: Work will ideally begin.