Co-creating a Social Needs Common Referral Approach in Minnesota 

In the current Minnesota environment, assisting people in getting resources they need is complex and at a minimum can require navigating multiple resource directories, interacting with several referral technology platforms, and contending with inconsistent data and technology standards. While valuable resources and tools exist, it is currently a fragmented approach, which can be burdensome and a barrier to successful resource referrals, especially for those people most vulnerable and in need of services and support. 

In 2021, Blue Cross Blue Shield of Minnesota (BCBS-MN) engaged Stratis Health and Collective Action Lab to explore whether the time was right for a cross-sector effort to work collaboratively toward a shared approach for connecting people in Minnesota to needed and culturally responsive resources such as food, transportation, housing, and health care. The results of this phase indicated strong multi-sector interest and willingness.  

In 2022, a Guiding Council was established to direct the work, coordinated and facilitated by Stratis Health and Collective Action Lab. The Guiding Council is comprised of 13 community organizations, 8 health care organizations, 3 payers, and two cross-sector organizations (Department of Human Services, and HealthPartners, as both a health plan and care delivery organization).  

Actions

• Assuring health equity by grounding and convening in alignment with the following principles:
  • Meaningful access to housing, food, and transportation is an essential element in assuring health equity
  • Solutions must be relevant across culture and statewide geography
  • Parity is essential – influence cannot be based on size or resources 
• Working with Health care, community, and payer organizations came together to articulate a shared vision for a statewide approach supported by universal standards, collaborative information directory, interoperable referral technology, human navigation, shared infrastructure, and sustainable financing. 
• Co-designing cross-sector solutions for the future and fostering shared accountability 
• Balancing urgency with the time for meaningful engagement  

We make lives better by…

• Engaging authentically with the community and leadership for community-led processes and solutions, which is a requisite for success 
• Collaborating with community leaders which fosters meaningful solutions 
• Creating an inclusive space for urban and rural needs, preferences, and considerations wherein processes and recommendations can be incorporated statewide. 
• Communicating and collaborating across sectors and having a shared vision for action.