Policy & Practice | Spring 2026

platform. When a caseworker deter mines that someone qualifies for food assistance, the system identi fies relevant community services, enables closed-loop referrals with the person’s consent, and tracks whether they engage with nutrition counseling and local food resources. It creates visibility into whether refer rals are helping, if barriers still exist, and what additional support might improve outcomes. This connectivity transforms scat tered programs into coordinated care—particularly important for rural communities where distance between services creates barriers. The platform integrates with existing 211 help lines, community health centers, food banks, and local organizations that families often contact first when in crisis. For rural residents who may drive long distances to reach services, digital coordination allows them to access comprehensive support without multiple trips. The bi-directional nature of this connection matters enormously. Community organizations become pathways into comprehensive support without requiring county hiring. The food pantry volunteer helping a family can also help facilitate their SNAP application, knowing that person will be seamlessly connected back to county eligibility systems. Community health workers can coordinate with Medicaid caseworkers, creating unified case management that addresses medical appointments, medication access, nutrition support, and trans portation barriers together. For Monroe County’s partner ship with TogetherNow, a nonprofit social innovation organization sup porting Medicaid innovation, this infrastructure enabled what the 1115 Waiver intended: addressing social determinants of health by connecting clinical care to community-based interventions. IBM and TogetherNow are leveraging the Connect360 platform— branded locally as MyWayfinder—to enable coordinated service delivery under New York State’s 1115 Waiver. MyWayfinder is TogetherNow’s imple mentation of Connect360, tailored to the Finger Lakes Region’s provider

maintaining strict confidentiality essential for their safety. Survivors report feeling that the system protects rather than exposes them. These outcomes—sustained engagement with trauma-informed care, improved safety, and better long-term health— depend on information sharing between law enforcement, health care providers, and social services while maintaining privacy protections that traditional siloed systems either over restrict or inadvertently compromise. The pattern is consistent: when services coordinate around the person rather than requiring them to coordi nate services, health improves. When caseworkers can see the full picture of someone’s needs and engagement across systems, they can connect people to appropriate interventions. When referrals include follow-up on whether services were accessed, gaps in care can be addressed rather than overlooked. How Coordination Happens: The Infrastructure Behind Better Outcomes These improved outcomes require technical and social infrastructure that most counties have not yet estab lished: the ability to share information securely across organizations, track referrals through completion, update eligibility rules rapidly when policies change, and understand which combi nations of interventions lead to lasting improvements. IBM Connect360 is a configurable social care coordination platform that connects the systems health and human services agencies, com munity organizations, and health care providers already use—giving caseworkers, care coordinators, and community partners a shared view of each person’s needs, referrals, and services in one place. Rather than replacing existing systems, Connect360 acts as the connective layer between them, enabling closed loop referrals, consent-based data sharing, and outcome tracking across organizational boundaries. This technology works by con necting providers, community-based organizations, regional health infor mation exchanges, and state or county agencies around a person-centric

Krithika Sudeswaran is a Business Architect and Delivery Lead at IBM Consulting.

Ross Maughn is Chief Technology Officer for State, Location and Education US, at IBM Consulting.

Eric Kane is Associate Partner and Offering Lead for IBM Community Health at IBM Consulting.

Maryam Ghariban is an Associate Partner at IBM Consulting.

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Policy & Practice Spring 2026