From Referral to Enrollment — At the Point of Care
Overview
A leading obstetric care program partnered with ITO Health to support expectant and new mothers facing social challenges during and after pregnancy. Using ITO HealthBase, community health workers moved from identifying needs to completing applications at the point of care — giving families critical supports at a vulnerable moment in their lives.
The Challenge
Clinicians and community health workers identified patients struggling with food insecurity, income instability, and childcare pressures. But frontline staff lacked tools to move beyond referrals. Applications for key programs like Temporary Disability Insurance / Temporary Caregiver Insurance (TDI/TCI) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were especially burdensome, often requiring multiple appointments and long wait times. The result: patients were screened, needs were documented, but enrollment didn’t happen. Staff were stuck in a referral-only model with no way to close the loop.
The Solution
The program deployed ITO HealthBase to enable community health workers to facilitate applications directly — at the point of care, during existing patient interactions. Instead of handing patients a referral and hoping they followed through, CHWs could complete enrollment on the spot.
With ITO HealthBase, community health workers could:
- Screen for social needs across food, income, childcare, and benefits eligibility
- Complete applications for TDI/TCI, WIC, and other programs alongside the patient
- Move families from identified need to enrolled in benefits before discharge
- Reduce the number of appointments and follow-up steps required for enrollment
The results
| Metric | Result |
|---|---|
| Applications facilitated | Hundreds of completed applications in the first six months |
| Patient access to benefits | Critical financial and nutritional supports secured during pregnancy and postpartum, before discharge |
| Staff follow-up burden | Reduced follow-up burden — staff confirm enrollment in real time rather than tracking whether patients completed applications on their own |
| Enrollment timing | Benefits secured at the point of care when timing matters most, rather than left to follow-up that often didn’t happen |
The shift from referral to enrollment meant families received support during pregnancy and postpartum — when timing matters most — rather than being left to navigate complex application processes on their own.
Why this matters for your business
Closing the last mile between referral and enrollment
The core finding: the gap wasn’t in screening or identifying needs — it was in the last mile between referral and enrollment. HealthBase closed that gap by making applications part of the care workflow, not a separate administrative process.
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