Implementing a Community Referral Network in NYC

April 5, 2023

Cost:  $199
Date: Wednesday, April 5, 2023; 1-2PM ET

Implementing a Community Referral Network in NYC

To increase access to social needs resources, the Bureau of Equitable Health Systems (BEHS) at New York City Department of Health and Mental Hygiene implemented a community referral platform among organizations serving in neighborhoods with highest health disparities. Organizations include Community Based Organizations (CBOs) and healthcare organizations. The platform provides a robust digital resource directory that makes it easy to search for services and share lists of resources to clients and patients. Resources include but are not limited to food pantries, SNAP assistance, mental health counseling, tenant’s rights education, and immigration support. The platform also enables organizations to electronically send to and receive referrals from each other. As part of the implementation, the CBOs and healthcare organizations also receive support to build their capacity in closing referral loops and optimizing usage of the platform’s features. 

This presentation will describe lessons learned in building a network of CBOs and healthcare organizations utilizing a community referral platform.  We will discuss successful strategies in driving adoption including offsetting cost, technical assistance, partnership development, and identification of place-based resources. We will also discuss solutions to mitigate barriers that required significant attention to address such as organizational and staff buy-in, metric development and workflow planning.

Target Audience

•    Health Plans
•    Health Systems
•    Hospitals
•    Managed Behavioral Healthcare Organizations
•    Population Health Organizations
•    Wellness organizations leveragers are the federal government, states and employers 

Learning Objectives

At the conclusion of the webinar, participants will be able to:

  •   Describe considerations for implementing a community referral platform in CBOs and healthcare organizations 
  •   Identify planning and technical assistance strategies to foster adoption and uptake of a community referral platform 
  •   Apply strategies in building linkages and partnerships between CBOs and healthcare organizations

Related Content:
NCQA Health Innovation Summit, October 23-25, 2023
Gaylord Palms Resort and Convention Center
Orlando, Florida

Course summary
Course opens: 
Course expires: 
Event starts: 
04/05/2023 - 1:00pm EDT
Event ends: 
04/05/2023 - 2:00pm EDT

Donna Castelblanco, MBE, PCMH CCE

Donna Castelblanco (she/her/ella) is a daughter of Colombian-Ecuadorian immigrants. She serves as a Social Care Integration Project Manager at the New York City Department of Health and Mental Hygiene. She supports population health equity initiatives in primary care and reproductive justice. Donna manages the agency’s growing network of partners that use a community referral platform to address the social care needs of New Yorkers. Donna is also a trauma-informed, prenatal yoga teacher.

Prior to joining the NYC Department of Health, Donna coordinated community-based evaluation research at a home visiting program in New Jersey. She also worked at NYU/Bellevue Hospital coordinating clinical research studies on homelessness prevention, substance use, and social determinants of health.

She earned her Master of Bioethics from the University of Pennsylvania and is currently a first-year doctoral student in the Johns Hopkins Doctor of Public Health, Health Equity and Social Justice program.


Janice Mango, MPA, PCMH CCE

Janice Magno (She/Her) serves as the Executive Director of Community Healthcare Strategic Partnerships​ for the Bureau of Equitable Health Systems. She leads a portfolio of initiatives and strategic partnerships to implement innovative care models that strengthen the primary care delivery system.  She oversees teams that provide technical assistance to primary care practices, FQHCs, and health systems on medical home transformation, capacity building for addressing health equity and sustainability in value-based payments. She also oversees BEHS’ collaboration with payers, accountable care organizations, qualified entities, government agencies, and other key stakeholders.  Janice received her MPA in health policy and management from New York University’s Wagner Graduate School of Public Service.

This live course grants 1.0 Continuing Education Unit (CEU) points for PCMH Certified Content Experts.  

* Please note – You must attend the entire program to be eligible for total number of contact hours.


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