Policy & Practice | Spring 2026

caseworkers avoid or that require workarounds undermining data quality. What distinguishes outcomes focused approaches is attention to how work actually happens. The platform evolves through continuous feedback from caseworkers, community members, community health workers, 211 partners, and people receiving services. When users say a workflow adds unnecessary steps, it gets streamlined. When community health workers identify barriers to documen tation, interfaces are redesigned. When caseworkers find the system genuinely helpful rather than bur densome, they document referrals consistently. When documentation is consistent, agencies can identify which interventions work. When community partners find coordination easy rather than frustrating, they engage more fully in integrated care. Sustaining Impact: Long Term Outcomes Require Durable Solutions Pilot programs often demonstrate promising results that fade once funding ends or staff turnover occurs. Counties need approaches that sustain impact despite budget uncer tainty, policy changes, and personnel transitions. Configuration-based plat forms supporting integrated service delivery address these sustainability challenges. When new reporting requirements emerge, dashboards can be configured to capture needed metrics. When community partner ships expand, new organizations can be integrated without system over hauls. For the Los Angeles County Domestic Violence Project, this dura bility has enabled years of sustained support for survivors. Secure coordina tion between law enforcement, health care, and social services continues operating reliably despite staff changes and evolving regulations. Measuring What Matters: Understanding Which Interventions Improve Lives Perhaps the most profound shift that coordinated infrastructure enables is moving from measuring activities to measuring outcomes.

Traditional systems count applica tions processed and referrals made. Integrated approaches enable tracking completed referrals, sustained service engagement, and long-term health and social outcomes. This includes both qualitative and quantitative data supporting the idea that systems work better when they are integrated and person-centered. One standout metric is a nearly 70 percent referral comple tion rate across a network of more than 40 connected providers. Counties implementing social and technical infrastructure can better answer important questions: Are the services we provide improving residents’ well being? Are resources reaching those who need them most? What Becomes Possible: Centering People and Community Well-Being The vision emerging from communi ties achieving better outcomes despite resource constraints is about what becomes possible when health, nutri tion, housing, economic stability, and safety are treated as interconnected aspects of well-being rather than separate bureaucratic categories. Technology enables this coordina tion by handling the data integration, referral tracking, and policy compli ance that have historically consumed staff capacity—allowing workers to focus on understanding individual needs and connecting people to support. The path forward for com munities facing tighter budgets and growing needs lies not in doing less but in coordinating better—treating every interaction as an opportunity for com prehensive support and continuously improving based on what actually improves lives. Communities exploring integrated social care infrastructure often begin with a pilot focused on a specific population or workflow. Starting with a defined use case allows agencies to evaluate coordina tion, staff adoption, and reporting value before scaling. States, counties, health systems, and community col laboratives seeking to advance social care coordination or rural health trans formation are invited to contact IBM to learn more about program design and potential pilot approaches.

landscape and community needs. Once live, the pilot will make it easier for Medicaid members to be screened for social care needs, assess eligibility for reimbursable nutrition, transporta tion, housing, and care management services, and coordinate referrals through the Social Care Network for the Finger Lakes Region. Adapting When Policy Changes: Maintaining Outcomes Through Transitions Recent SNAP policy modifications presented a severe test for Monroe County. Federal changes to work requirements for able-bodied adults without dependents created imme diate confusion among residents, who flooded local Department of Social Services offices with calls asking whether new age thresholds and exemption criteria applied to them. The county responded with a digital self-service screener developed and deployed in less than 30 days. The tool asked simple questions about age, work activities, health status, and caregiving responsibilities and instantly provided personalized results. More than 2,000 screenings in the first 2.5 months demonstrated imme diate adoption. Sixty-five percent of individuals identified an exemption and received clear next steps to notify the agency and avoid losing benefits. Another 6 percent learned they were subject to work rules and were con nected to job placement, training, and volunteer opportunities through the integrated platform. This rapid response helped residents understand their status quickly and prevented unnecessary disruptions in nutrition assistance. Staff were able to focus more time on complex cases rather than answering thousands of routine eligibility questions. Community-Informed Design: Systems That Reflect How Work Actually Happens The most sophisticated technology fails if frontline workers cannot or will not use it effectively. County agencies have spent millions on systems that

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Spring 2026 Policy & Practice