The Wellbeing Care Community platform unites community-based organizations, health, social services and more to address Community Care Coordination needs.

SDOH

Social Drivers of Health Screening and Referral Coordination

Housing instability, food insecurity, lack of transportation, and digital exclusion drive poor health outcomes in every region. While health systems are increasingly investing in Community Care Hubs and cross-sector partnerships, the lack of digital infrastructure limits impact.

Community Challenges

Why Traditional Systems Fall Short

Referrals are often managed in systems that do not close the loop. There’s no standardized tracking of what happens after a food or housing referral is made.

Community-based organizations lack tools to measure impact, and healthcare systems are disconnected from social care providers.

Without shared systems, promising collaboratives struggle to demonstrate ROI or secure long-term funding, and people needing help fall through the cracks.

Wellbeing Community Care

Infrastructure for Whole-Community Coordination

WCC enables regions to operationalize strategies that support workforce development, economic mobility, and poverty reduction initiatives through a connected ecosystem of partners, programs, and community resources.

Shared SDOH Assessments and Success Plans

Personalized support plans tied to Social Drivers of Health (SDOH) needs across the life course.

Closed-Loop Referrals and Outcomes Tracking

Real-time feedback loops between referral senders and social service providers.

Role-Based Access and Multi-Sector Engagement

Supports CHWs, peer navigators, clinic staff, and CBOs with tailored tools.

myWellbeing Directory Integrated Resource Directory

Curated local listings with automated updates and mobile access

Reporting and Analytics

Aggregate and client-level insights for funders, payers, and community stakeholders.

Strategic Advantage

Equity, Efficiency, and Scale

For Individuals

Faster connection to food, housing, and support — without repeating their story. Personalized care plans empower people to take charge of their wellbeing.

For Providers

Easier coordination, clearer insight into client progress, and better alignment with care teams. Less duplication and more time delivering services.

For Communities and State Agencies

WCC helps regions operationalize health equity goals, align with Medicaid transformation initiatives, and meet requirements for CBO involvement in value-based care.

Why It Matters

Complements and enhances existing 211 and e-referral systems.
Supports Community Care Hub accreditation and grant compliance.
Enables rural and urban collaboratives to scale with shared infrastructure.

WCC is the backbone technology for place-based initiatives focused on health equity, prevention, and resilience.

Definition

What Are Social Drivers of Health?

Social drivers of health, also called social determinants of health (SDOH), are the non-medical conditions in which people are born, live, learn, work, and age that shape health outcomes. They include housing, food access, transportation, income and employment, education, safety, and social connection. The related term health-related social needs (HRSNs) refers to the specific, individual-level version of those conditions, meaning the concrete unmet needs a given person has right now, which is the distinction drawn in this explainer on health-related social needs in connected care.

Screening for social needs only creates value if a referral actually reaches a partner organization and closes with a known result. That closure is the hard part, and it is where most SDOH efforts stall. The Wellbeing Care Community platform provides shared screening, closed-loop referral workflows, consent management, and cross-sector reporting so healthcare, behavioral health, and community organizations can see outcomes rather than just activity, an approach described in unlocking community potential through a hub for collaborative care.