Social Care Providers
Social Care Providers / Community Based Organizations

This is a multisector, diverse set of organizations who serve a diverse set of clients, many who are experiencing poverty, or homelessness, developmental disabilities, childhood and adult traumas, to older adults working to receive care at home, while managing multiple transitions in care. While we have made some effort to call out the needs of just a few of the sectors, it’s important to note the limitations of putting large, complex sectors in these broad categories “Social Care Providers / Community Based Organizations.” Our purpose in doing so is to work in partnership with these organizations to identify the most important opportunities for data exchange that can improve service access and delivery, especially when that process touches healthcare providers, and will need to interact with healthcare data standards.

Continuums of Care (CoC), Homeless Shelters and Housing Service Providers

Continuums of Care (CoC), Homeless Shelters and Housing Service Providers face significant challenges in coordinating the services for clients who may have multiple and complex needs, including, poverty, mental health issues, substance abuse, and chronic health conditions. These organizations often operate with limited resources and must navigate a complex system of government regulations and funding streams. Additionally, these organizations often struggle to coordinate care with other providers, because services and data continue to operate in silos making it difficult to ensure that clients receive the comprehensive services they need.

Aging and Disability Networks

Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs) face several challenges in fulfilling their mission of supporting older adults and individuals with disabilities. Here are some of the key hurdles they encounter:

  • Complexities in Care Coordination & Lack of Cross Sector Interoperability:

    AAAs and ADRCs connect clients with a wide range of services across various sectors - medical, social, and government. However, these sectors often have separate data systems and communication channels, making it difficult to ensure a smooth and coordinated flow of care.

  • Limited Resources:

    Funding for AAAs and ADRCs often doesn't match the growing demand for services from a rising aging population. This can limit their ability to hire sufficient staff and offer robust programs.

  • Reaching Underserved Populations:

    Outreach efforts may not resonate with all communities, particularly those with cultural or language barriers. This can create gaps in service access for vulnerable populations.

  • Navigating Eligibility Processes:

    Programs offered by AAAs and ADRCs often have specific eligibility requirements. This complexity can be overwhelming for clients and their families, leading to delays or missed opportunities for assistance.

  • Keeping Up-to-Date Information:

    The landscape of available services and resources is constantly changing. Maintaining accurate and comprehensive information can be a challenge for AAAs and ADRCs.

Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs) face challenges in coordinating care effectively because systems across medical, social, and government sectors often don't communicate seamlessly. Limited funding hinders their ability to meet rising demands for services. Additionally, outreach to underserved populations can be difficult, and navigating complex eligibility requirements creates barriers to accessing important services. Keeping up-to-date on the ever-changing landscape of resources is another significant challenge.