Reducing Barriers to Community Resources: How Findhelp is Advancing Whole-Person Care

In behavioral health and human services, the distance between identifying a need and meeting it is often where care breaks down. That gap becomes even more pronounced when addressing social determinants of health (SDOH), where clinicians may recognize a challenge like food insecurity, housing instability or lack of transportation but don’t possess the tools to ensure meaningful follow-through. 

That was the focus of a recent client webinar “Reducing Barriers to Community Resources with Findhelp: Uniting Platforms for Better Outcomes” exploring how Findhelp, a leading social care platform powering a connected safety net, is helping organizations close that gap. By embedding social care directly into clinical workflows, the combined solution is reshaping how providers connect individuals to community-based services, and how they measure whether those connections actually make a difference. 

When these two systems operate independently, staff often have to step outside their primary workflow to search for resources or manage referrals. Instead, this integration brings Findhelp directly into the myAvatar environment as a natural extension of clinical care. 

Meet the Speakers 

• Brittany Whittington, LCSW, Director of Accountable Care, Integral Care 
• Rachel Harris, Director, Enterprise Solutions, Findhelp 
• Alex Prince, Managing Solution Consultant, Netsmart 
• Ryan Rooks, Senior Channel Strategist, Netsmart  

Embedding Social Care into Clinical Workflows Changes Everything 

For individuals, the biggest shift is experiential. When social care is embedded directly into clinical workflows, needs can be addressed in real time, during the care interaction itself. Rather than being handed a phone number or directed to a generic resource, individuals are connected to specific, local services that reflect their immediate circumstances. 

This approach allows providers to move beyond less helpful national recommendations and instead zoom in to local resources. “Findhelp is hyper-local,” Whittington said. “You’re able to say ‘in a community here are the food pantries available. Here are their hours of operation. Here’s what it looks like for utility assistance in your area.’”  

That level of specificity matters. It reduces barriers, increases the likelihood that individuals will follow through and creates a more supportive experience overall. When access to resources is immediate and tailored, people are better positioned to take the next step. 

Closed-Loop Referrals Provide Visibility That Was Previously Missing 

For many, one of the most frustrating aspects of navigating social services is uncertainty—whether a referral will lead to actual help, or whether they’ll need to start over somewhere else. Closed-loop referrals help eliminate that ambiguity by ensuring that connections don’t end at the point of referral. 

With this approach, providers can track whether a person was reached, whether an appointment was scheduled and whether services were ultimately delivered. That continuity creates a more reliable experience for individuals, who no longer need to navigate the system alone. 

Just as importantly, it allows organizations to better support individuals who may fall through the cracks. Visualizing the full referral journey enables teams to confirm outcomes and step in when needed. As Rooks pointed out, Findhelp can help providers determine “Was that individual reached by that referral partner? Was an appointment scheduled? Were services received?”  

For individuals using the service, that translates to fewer dead ends and a stronger sense that someone is actively supporting their progress. 

 

Data Turns Social Needs into Strategic Insight 

While analytics often live behind the scenes, their impact is felt directly. By understanding what people are searching for and where needs are increasing, organizations can adapt services to better reflect real conditions on the ground. 

One example shared during the session stood out: a noticeable increase in searches related to food insecurity. That signal prompted immediate action. Organizations used that insight to inform partnerships, allocate resources and introduce new services designed to meet rising demand. 

“We’ve seen a pretty significant uptick in the searches for food insecurity resources,” Whittington said. "We can use that information to help with grant planning and new partnerships...to address food insecurity for our clients.”  

For individuals, this kind of responsiveness means services are more aligned with actual needs, rather than lagging behind them. It also increases the likelihood that when they seek help, relevant resources are available and accessible. 

Staff Experience Drives Adoption and Impact 

Individual outcomes are closely tied to how effectively staff can engage with the tools available to them. When systems are intuitive and easy to access, staff are better equipped to focus on what matters most, helping individuals navigate complex challenges. 

The discussion highlighted how simplifying access through features like single sign-on removes friction and allows staff to engage more consistently. But beyond usability, it also enables more meaningful interactions. 

Instead of spending time navigating systems, staff can spend more time supporting individuals directly. This shift is especially important in high-need situations, where timely intervention can make a significant difference in whether an individual receives support. 

Dedicated Roles Strengthen Outcomes and Accountability 

Another critical factor related to improving individual outcomes is ensuring that someone is actively guiding the journey. Organizations that assigned dedicated staff, such as community health workers, to manage referrals saw a measurable difference in how people experienced care. 

These crucial team members don’t just send referrals—they stay engaged, helping individuals navigate options, troubleshoot barriers and connect to the right services, even if those services fall outside the organization itself. 

“One of the benefits of having our community health workers managing the inbound referrals is that they're trained to help them get resources, whether it's in our organization or outside of our organization,” Whittington said. “Our team is going to help support them and connect them to whatever they need.”  

Whole-Person Care Becomes More Measurable—and More Real 

At its core, this approach reinforces a more complete model of care that recognizes the interplay between clinical, social and environmental factors. By identifying social needs within the care journey and connecting them directly to actionable resources, providers can respond more effectively to the realities individuals face. 

The ability to track outcomes further strengthens this model. Organizations can see what actually happened—how many individuals received support, what types of services were most utilized and where gaps still exist. 

As Whittington noted, “Here’s how many closed loop referrals were provided. Here’s how many folks were able to get assistance.”  

For myAvatar clients, this means care is no longer limited to intent—it’s measured by results. The integration of myAvatar and Findhelp represents a more connected approach to care. By aligning clinical workflows with community resource networks and layering in actionable data, organizations are better equipped to address the full spectrum of individual needs.