Maintaining Social Care Delivery After CHW Funding Loss
Overview
A large federally qualified health center (FQHC) partnered with ITO Health to sustain social care delivery after the loss of dedicated community health worker (CHW) funding. Through a hybrid model combining ITO HealthBase with an embedded ITO Health CHW, the center maintained its ability to address social determinants of health (SDoH) for a large patient base — without the funding that previously made it possible.
The Challenge
Without dedicated CHW funding, the health center risked losing its ability to address social determinants of health for its patient population. Staff in medical and behavioral health clinics had limited time and tools to navigate benefit applications, track follow-up, or coordinate across programs. The core problem wasn’t a lack of awareness — clinicians knew their patients had social needs. It was a lack of infrastructure to act on those needs at scale once the dedicated workforce was gone.
The Solution
ITO Health worked closely with the health center’s leadership and social services teams to co-design and implement ITO HealthBase. This wasn’t just a technology deployment — it included an embedded community health worker from ITO Health who worked alongside clinical staff.
The embedded CHW used ITO HealthBase to:
- Screen patients for social needs during clinical visits
- Auto-complete applications for food assistance, housing, and Medicaid redeterminations
- Submit utility protection letters during visits
- Coordinate follow-up across programs and agencies
Together, the ITO Health and health center teams refined workflows, shared data, and coordinated follow-up — creating a shared care model that allowed the center to continue providing robust social care despite funding cuts.
The results
| Metric | Result |
|---|---|
| Patient benefit access | Applications completed during visits rather than handed off as referrals |
| Emergency department impact | Reduced avoidable ED visits through proactive support for social needs that would otherwise escalate |
| Team coordination | Strengthened coordination across medical, behavioral health, and social services |
| Sustainability | Established a framework for addressing social needs at scale without dependence on CHW grant funding |
The center demonstrated measurable value to payors and established a sustainable model for social care delivery that doesn’t depend on dedicated CHW grant funding.
Why this matters for your business
From grant-dependent to infrastructure-based social care
The center didn’t just replace lost funding with technology — it built a more sustainable model. By combining a platform (HealthBase) with professional services (an embedded CHW), ITO Health helped the center move from grant-dependent social care to infrastructure-based social care.
Ready to see similar results?
Learn how ITO Health can help your federally qualified health center achieve measurable outcomes.