Co-creating a Social Needs Common Referral Approach in Minnesota 

In the current Minnesota environment, assisting people in getting the 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 to health care and health-related social needs (HRSN) such as food, transportation, and housing. 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 comprises 13 community organizations, eight health care organizations, three 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:
  • Addressing social drivers of health (SDOH) by providing meaningful access to housing, food, and transportation is an essential element in assuring health equity
  • Crafting solutions that are relevant across culture and statewide geography
  • Maintaining 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.