Inside the Bridges to Resolution Summit: Why Social Care Networks Need Design, Not Just Software
On September 15, 2026, the Bridges to Resolution Summit took place at the Robert S. Strauss Building in Washington, D.C., hosted by Syracuse University and sponsored by The Heinz Endowments, Northwestern University, and the D’Aniello Institute for Veterans and Military Families. It brought together state Medicaid directors, healthcare executives, public human services leaders, and researchers around one central question: how do we move social care networks beyond software platforms and simple referrals toward hub-managed systems that deliver actual service resolution?
Here’s a full recap of what was discussed.
Opening Welcome: Hard Lessons in Network Sustainability
Megan Andros, Program Officer at The Heinz Endowments, kicked things off with ten years of data from PAServes, part of the AmericaServes veteran network launched in 2015 across three Pennsylvania counties.
The results were striking: when the network operated with a human-navigated coordination hub, shared referral protocols, and CBO capacity tracking, it achieved an 83% service receipt rate. It proved that a well-run referral network functions as a genuine health intervention, reducing ER visits and boosting primary care use.
But when philanthropic funding ended and federal suicide-prevention grants (the Commander John Scott Cannon Act) took over, the new funding model measured only narrow crisis response, not upstream network health or hub governance. The result: public dashboards went dark, steering committees dissolved, and network accountability quietly eroded.
Andros’s takeaway for public leaders: “design determines outcomes, not technology.” She urged them to “fund people, not platforms” by embedding service receipt metrics directly into state contracts, RFPs, and waiver evaluation plans.
Keynote: Defining the Terms of Resolution
Dr. Michelle Shumate, Delaney Family University Research Professor at Northwestern University/NNSI Lab Director, set the tone for the day. She grounded the abstract stakes in real stories like “Samantha,” a disabled woman in recovery who emailed 65 charities before securing housing. The story illustrated how fragmented systems leave vulnerable people to navigate dead ends alone.
Shumate offered five foundational definitions for the field:
Referral: the moment one organization points a person to another
Network: a formal collaborative arrangement between independent organizations using an agreed-upon process
Resolution: the point where a client’s need is actually met, not just logged or routed
Hub: the central locus where system-wide accountability lives
Design: the deliberate architectural choices governing roles, accountability, and follow-up workflows
The evidence gap is stark. National service-receipt rates vary dramatically by network architecture:
43%–88% in networks with human navigators and/or CBO reimbursement
21%–39% in technology-only, peer-to-peer vendor platforms
~25% baseline for traditional 211 call centers offering self-service information
The economic case is just as compelling: $164 PMPM in savings from North Carolina’s Healthy Opportunities Pilots, $283/year per enrollee in California’s Whole Person Care, $375–$1,100/year in the national Accountable Health Communities pilot, and 43% lower odds of low birth weight in Pathways Community Hubs.
Her call to action: redirect funding away from tech-only vendors toward human “air-traffic-control” navigators and direct CBO service delivery.
Policy Panel: Blending & Braiding Funding for Referral Hubs
Facilitated by Brandon Wilson (COO, Asheville Buncombe Community Christian Ministry/NCServes), this panel featured Dr. Devdutta Sangvai (Secretary, NC DHHS), Liz Whitworth (Oregon Health Leadership Council), and Lisa Parker (Oregon Health Authority), discussing the transition from social care experimentation to permanent Medicaid 1115 waiver implementation.
Key takeaways:
Ecosystems need a hybrid model: central hubs as the safety net and governance backbone, with peer-to-peer connections handling routine, simpler matches.
Fee-for-service rates under waivers are often too low to keep CBOs solvent, and capacity-building funds frequently run out before five-year waivers conclude.
Healthcare CFOs work in 1- to 2-year budget cycles, while savings from social interventions often take longer to materialize.
Federal policy shifts, like HR1 work requirements, risk overwhelming county eligibility offices with administrative burden.
Dr. Sangvai framed the core budget dilemma bluntly: “If you’re going to pay for this, what are you not going to pay for?” He pushed for moving past process metrics toward rapid clinical outcomes, like A1c reductions within six months, evaluated by independent local academic partners such as community colleges.
Practice & Design Sessions: Beyond Software and Referrals (APHSA)
Marci McCoy-Roth, Chief Impact & Innovation Officer at APHSA, shared survey data showing 81% of state agency leaders see cross-system alignment as core to their mission, while 68% cite technology limitations as a barrier. But deeper diagnosis revealed IT problems are usually symptoms of policy, governance, or workflow gaps underneath.
She presented Data SAIL’s (State Action and Innovation Lab) initiative in Kentucky. Although Kentucky already possessed advanced infrastructure through KY-NET and 211 to verify that referrals were made and closed, state leaders recognized that they could not determine whether resolving a social need actually led to wage increases, sustained employment, or educational credentials. To address this gap, Kentucky utilized Data SAIL innovation funding and technical assistance to link two separate state bodies—the Cabinet for Health and Family Services and the Education and Labor Cabinet—by integrating KY-NET social care data with longitudinal workforce and education records through KYSTATS (the Kentucky Center for Statistics). This cross-agency integration establishes a continuous improvement loop that enables the state to map community needs, connect completed social referrals directly to workforce outcomes, learn which interventions are most effective, and refine frontline service delivery accordingly
Reducing Benefits Churn (Code for America)
Dr. Daniel Mintz (Director of Safety Net Policy) and Ashley “Tez” Cortez (Principal Service Designer) outlined why public sector tech initiatives fail: vague goals, solving the wrong problem, ignoring surrounding worker workflows, unready frontline staff, and treating launch day as the finish line instead of the start.
Their Washington, D.C. case study was telling: rather than rebuilding the public-facing benefits portal (already fast, under 20 minutes), worker shadowing revealed caseworkers were struggling with 7–8 duplicate records per individual. The fix was a lightweight browser extension that cleaned up data displays and dramatically boosted accuracy and speed.
Cortez demonstrated Service Blueprints, visual maps using Post-it notes to lay out client/worker swimlanes and system triggers. In one state Medicaid renewal pilot, this human-centered approach cut caseworker processing time from 70 minutes down to 11 minutes per case.
Mintz’s warning to state leaders: be wary of vendor pitches selling AI as a “magic wand.” Eligibility decisions must stay traceable, verifiable, and tied to clear human workflows.
Evidence from the Field: Design Versus Delivery
Moderated by Dr. Shumate, this panel featured Dr. Matthew Kreuter (Washington University in St. Louis) and Dr. Leslie Hausmann (University of Pittsburgh/VA Pittsburgh).
Kreuter emphasized that traditional 211 referral take-up sits at only ~25%. When clients fall through the referral gap, stress, depression, and health non-compliance all rise. And when two or more social needs co-occur, negative outcomes compound exponentially, demanding more intensive intervention.
He presented a Resource Allocation Grid, a 2×2 matrix comparing community problem prevalence against resource capacity, arguing communities need the courage to shift funding away from over-resourced, low-prevalence programs toward high-prevalence, resource-starved areas like housing and rent assistance.
Hausmann’s framing: “what gets funded gets done and measured.” She advocated for explicitly funding the slow, unglamorous work of building inter-organizational trust, because that is the true backbone of network performance.
The panel also covered three pathways into networks: expressed self-requests, clinical screening, and data-mining/predictive analytics. Kreuter noted a striking historical data point: 211 call volume detected the 2008 national housing crisis 6 to 9 months before it became national news.
The Community Hub Panel: CBO Capacity & Infrastructure
Facilitated by Dr. Joshua-Paul Miles (University of Illinois Urbana-Champaign), this panel included Camey Christenson (211 San Diego/CIE), Heather Black (United Way Worldwide), Paul Cantrell (USAging/Center of Excellence), and Dr. William Bleser (Administration for Community Living).
Highlights:
Christenson detailed 211 San Diego’s Community Information Exchange (CIE) model, maintaining single longitudinal client records for 387,000+ opted-in residents across 145 participating organizations and 18 system integrations (including HMIS and Epic CRM), funded through healthcare PMPM contracts.
Black argued states shouldn’t build new standalone platforms from scratch when 138-year-old community infrastructures like 211 and United Way already have scalable resource databases, trusted relationships, and disaster response capacity.
Cantrell and Bleser explained Community Care Hubs—central administrative entities managing HIPAA compliance, legal contracting, and billing so small, grassroots CBOs can focus on service delivery instead of administrative overhead.
Bleser noted that CMS’s budget is 556 times larger than ACL’s, urging CBOs and hubs to build capacity to bill permanent Medicare codes (health coaching, care management, diabetes self-management) alongside Medicaid waivers for predictable, long-term revenue.
Key Takeaways for Policy & Practice
The summit crystallized around four core principles:
Design over technology — Software alone doesn’t resolve social needs. Human navigators acting as “air traffic controllers,” backed by accountable hub structures, drive actual service receipt.
Fund the destination — A referral to an underfunded or non-existent service is a “bridge to nowhere” that erodes public trust. CBOs must be directly reimbursed for service delivery.
Measure service receipt, not referral closure — Administrative closure rates often exceed 85%, but that can mask real failure if only ~27% of clients actually receive services. State contracts must mandate tracking true resolution.
Leverage established hubs — States should partner with existing Community Care Hubs, 211s, and Area Agencies on Aging rather than building redundant parallel systems.