What We Do
Six Domains of Social Care
We address the social determinants of health that clinical care alone cannot resolve — connecting Illinois Medicaid members to the community-based support they need to thrive.
Service Area
Housing Stability
Safe, stable housing is the foundation of health.
Unstable housing is one of the strongest predictors of poor health outcomes for Medicaid members. Our network connects individuals and families to emergency shelter, transitional housing programs, rental assistance, eviction prevention, and long-term supportive housing — with care coordinators who navigate the process alongside them.
- Emergency shelter placement and navigation
- Transitional and permanent supportive housing
- Rental assistance and eviction prevention
- Housing-first case management
- Coordination with Illinois Housing Development Authority programs
Service Area
Food Security
No one should go hungry while managing a health condition.
Food insecurity directly undermines chronic disease management, mental health, and child development. We link Medicaid members to food pantries, SNAP enrollment assistance, medically tailored meal programs, and community nutrition education — removing barriers to consistent, healthy food access.
- Food pantry referrals and navigation
- SNAP enrollment and recertification support
- Medically tailored meal delivery
- Community nutrition education
- WIC and school nutrition program connections
Service Area
Community Health
Health care that meets people where they are.
Our community health work goes beyond clinical settings — embedding care coordinators in neighborhoods to support preventive care, chronic disease management, behavioral health navigation, and substance use recovery. We partner with FQHCs, community mental health centers, and local health departments across Illinois.
- Preventive care and wellness screenings
- Chronic disease management support
- Behavioral health and mental health navigation
- Substance use disorder recovery support
- FQHC and community clinic referrals
Service Area
Family Planning & Support
Supporting families at every stage, with dignity and care.
From prenatal care navigation to parenting support and family counseling, we provide culturally responsive, trauma-informed services that strengthen families. Our network includes doulas, family resource centers, early childhood programs, and domestic violence support services.
- Prenatal care navigation and doula support
- Parenting education and family counseling
- Early childhood development resources
- Domestic violence support and safety planning
- Family planning education and reproductive health referrals
Service Area
Justice-Involved Support
Reentry is a health issue. We treat it that way.
Justice-involved individuals face compounded barriers to health and stability upon reentry. Our network provides pre-release planning, Medicaid enrollment, care coordination, housing navigation, and community connection — reducing recidivism by addressing the social and health needs that drive it.
- Pre-release care planning and Medicaid enrollment
- Reentry housing and shelter navigation
- Substance use and mental health treatment linkage
- Employment and benefits navigation
- Community mentorship and peer support
Service Area
Care Coordination
The connective tissue of whole-person care.
Care coordinators are at the heart of our model — building trusted relationships with Medicaid members, navigating complex systems on their behalf, and ensuring that social and clinical care work together. Our coordinators are embedded in communities, not call centers.
- Comprehensive needs assessments
- Cross-sector care plan development
- Warm handoffs to partner organizations
- Ongoing follow-up and member engagement
- Data sharing and outcome tracking with MCOs
Deliver These Services Through Our Network
Community organizations providing any of these services are invited to join our statewide Medicaid social care network. We provide the infrastructure — you provide the community connection.