Problem
The Houston Food Bank (HFB) is Houston’s central agency for serving the city’s food-insecure population. Beyond this core function of distributing food to those in need of it, they have also created the Community Assistance Program (CAP), which helps individuals apply for state-funded social and health services, such as SNAP, TANF and Medicaid/CHIP, as well as linkage and referral services to other social service providers and other food bank programs.
The program sends and receives referrals from a variety of agencies, such as HFB’s partners, public access systems, and entities connected to their FIRST Link program, which ensures that healthcare partners around the city are cognizant of HFB’s services by training clinicians and following up with patients to see if the referred resources have been given to them.
Implementing this approach would provide tremendous assistance, particularly to the food-insecure and those in need of social services. In theory, a network is established between HFB and agencies within their referral-base, which allows for a “no wrong door” approach to care provision. This means that an individual can go to HFB with any social or medical need, and if HFB cannot provide the service or treatment themselves, they will work with Community Resource Navigators (CRNs) from HFB’s Referral Partner Program (RPP) to identify and submit a referral to any agency within their network capable of meeting their needs.
However, the steps required to achieve this are spattered with challenges. Currently, these additional services are tracked in separate disparate systems without the use of a unified solution. The complex workflows for both receiving and sending referrals from HFB without a dedicated solution to support robust electronic bi-directional linkage of services in the community limits the impact of this program. Given the expansion of HFB’s services, it also makes the tracking of outcomes across all Food Bank programs and at a broader community level much harder.
Solution
Our team has rolled out the path/discovery module for HFB to integrate data from different Food Bank data systems, spanning the greater Houston area, to gauge how combatting food insecurity can have a positive cascading effect on the social, economic, and health outcomes for individuals utilizing the Houston Food Bank’s resources. This data sharing and processing will inform and direct HFB’s RPP coordinators to the optimal referral agency to meet a patient’s unique set of needs.
In addition to path/discovery, our team has rolled out the path/net and path/bridge modules of the/path to manage and track activities within the CAP and FIRST Link programs. This provides a unified platform for tracking as well as real-time, bi-directional, electronic referrals both within HFB, as well as to external community partner organizations.
Additionally, using the platform closes the communication loop between agencies by integrating direct SMS text, voice calling, and email features into the path/bridge interface. All these features culminate to provide HFB with tools to connect individuals to resources, internally or externally, in real-time, while keeping those within the loop informed of their medical and social service history.
the/path, combined with the training on our Values-Based Model of care, creates a holistic approach integrating data, a care model, and resource connectivity that can be scaled to all Food Banks nationally.
To learn more about Houston Food Bank’s CAP program and other services, visit the Houston Food Bank website at www.houstonfoodbank.org
