INTEGRATION OF CARE COMMITTEE MEETING
April 15 2026, 10:00 – 11:54 AM
By Zoom Videoconference
DRAFT MINUTES
Members Present: Steve Hemraj (Co-Chair), Jeff Natt(Co-chair), Raffi Babakhanian, Victoria Bell, Billy Fields, Dorothy Farley, Ronnie Fortunato, Charmaine Graham, Christopher Joseph, Marcelo Maia, Cesar Nuñez, Jesus Robles, John Schoepp
Guest/Others Present: Iesha Reid (DC Department of Health Care Finance), Abby Stretz (CRISP DC), Ashley Coleman (DC Department of Health), Shannon GoPaul (DC Department of Health), Michelle Lopez, Veronica H., Lisa Dove
Staff Present: NYC DOHMH: David Klotz (Governmental co-chair), Doienne Saab, Michael Navejas, Laura Moya Adames, Abraham Omeyoma; Recipient: Johanna Acosta, Scott Spiegler, Sara Kramer
Agenda Item # 1: Roll Call/Moment of Silence/Minutes
Jeff N. and Steve H. opened the meeting and reviewed the agenda. Doienne S. conducted a roll call. Members were informed that the January Integration of Care Committee minutes had been circulated in advance. No corrections noted, and hence approved.
A moment of silence was held led by John S.
During announcements and early discussion, committee members shared resources and updates (https://indivisible.org/events/may-day-strong-no-work-no-school-no-shopping/), including community advocacy efforts and events (https://www.abilities.com/new-York). A moment of solidarity was expressed for a community member experiencing immigration-related challenges, with members affirming their collective support and commitment to community care and advocacy.
Agenda Item #2: Closed-Loop Referrals and FindHelp Overview
Presenters (Iesha Reid (DC Department of Health Care Finance), Abby Stretz (CRISP DC), Ashley Coleman (DC Department of Health), Shannon GoPaul) provided an overview of the DC Health Information Exchange (HIE) and its integration with LinkU, a social care referral platform that connects individuals to community-based services such as housing, food, and financial assistance. The model was developed after a series of multi-sectoral collaborative meeting with stakeholders to improve the health care systems ability to address barriers to care through a collaborative mechanism that could screen and provide closed-loop referrals for DC residents unmet social needs.
The DC model centers a whole-person approach to care, integrating clinical and social needs data to improve care coordination, access, and outcomes across systems.
Presenters described how LinkU is integrated into the HIE through single sign-on (SSO), allowing providers to:
- Conduct social needs screenings
- Search for community resources
- Make referrals
- Track referral outcomes through a closed-loop system
- Support follow-up and ongoing care coordination
The closed-loop referral workflow includes screening, referral, tracking, and confirmation of service connection, reducing duplication and improving continuity of care.
The platform utilizes a standardized needs assessment tool, capturing domains such as housing, food, transportation, mental health, substance use, and other social determinants of health to inform care planning.
A use case highlighting the WIC program demonstrated strong referral outcomes, including high response and closure rates, improved coordination across agencies, and secure communication between providers.
Implementation updates included onboarding 35 provider organizations (hospitals, FQHCs, and behavioral health providers), with ongoing efforts to expand adoption and utilization. Link U has been funded through two mechanisms: Ryan White Part A funds and DC Health Information Exchange – DC Medicaid Enterprise Funding.
Future developments include integration of z-codes, enhanced data sharing, and real-time notifications to address unmet social needs and support population health management.
In the past year, there have been 62,979 searches via LinkU, top searches included HIV testing and food pantry services.
Discussion & Considerations
During and following the presentation, Committee members engaged in a robust discussion, raising key questions and considerations related to implementation, funding, and applicability to the NYC context.
- A broader discussion focused on funding and scalability, with members exploring whether Ryan White Part A (RWPA) funds could support the development of a similar closed-loop referral and health information exchange system in NYC. Presenters shared that DC leverages Medicaid Enterprise funding and also utilizes RWPA funds to support LinkU.
- Participants emphasized the importance of leveraging existing platforms already used by providers, such as Unite Us and FindHelp, to avoid duplication and support adoption. Additional discussion highlighted opportunities to utilize 1115 Waiver infrastructure funding to support system development and integration.
- Members also raised important consumer-centered considerations, noting the need to ensure that clients understand how their data is collected, shared, and used. Concerns were expressed about systems being developed without sufficient consumer input, emphasizing the importance of incorporating community voice into design and implementation.
- Discussion also highlighted the potential benefits of closed-loop systems, including improved service utilization, stronger coordination across providers, and enhanced continuity of care, particularly for individuals moving across jurisdictions.
- Members inquired about outreach and awareness strategies, including how LinkU is marketed to communities. Presenters noted the use of transit advertising and partnerships with providers and community-based organizations to increase awareness and utilization.
Next Steps and Last Thought
- Closed-loop referral systems can strengthen care coordination, accountability, and outcomes
- Successful implementation requires cross-sector collaboration and provider buy-in
- NYC has opportunities to build on existing platforms and funding streams rather than duplicating systems
- Consumer voice, transparency, and equity must remain central to system design
- Committee members expressed strong interest in exploring adaptation of this model within the NYC EMA; David K. and Doienne S. to follow up with Public Health Solutions (PHS) on potential opportunities to implement a similar model for RWPA
Adjournment
There being no further business, the meeting was adjourned.
The Next Steering Committee Meeting will be held on Wednesday, May 20, 2026
10-11:30 AM.
There being no further business, the meeting was adjourned.
