- Shannon Smith, Assistant Vice President of Clinical Success
Healthcare outcomes are shaped not only by medical interventions but also by the environments in which people live. Factors such as food access, housing stability, transportation, and income security can determine whether care plans succeed or fail. These are the social determinants of health (SDOH) that define a person’s ability to recover, manage chronic conditions, and maintain overall well-being.
Recognizing that clinical care cannot operate in isolation, Zyter|TruCare integrates Findhelp, a leading social care network, directly within our TruCare care management platform. This integration enables care teams to connect members to local, community-based services as part of their existing clinical workflows, advancing a more coordinated and equitable approach to care delivery.
The CMS Rural Health Transformation program, which will start funding state Medicaid rural health initiatives in 2026, will drive an even greater need for integrated social care network solutions like Findhelp.
Connecting Members to Social Resources Within Care Workflows
The Findhelp integration within TruCare allows users to locate and refer members to community programs that address a wide range of needs, including food insecurity, housing instability, transportation barriers, and other critical social factors. The recent lapse of Supplemental Nutrition Assistance Program (SNAP) benefits is an example of why health plans need the flexibility to quickly redirect members to alternative community resources.
TruCare handles this need seamlessly by providing an embedded iFrame within the application, providing Care Managers with a single system view and solution. Care Managers create and track referrals for their members directly within Findhelp, ensuring full visibility into each member’s progress through linked cases, structured notes, and secure messages in TruCare.
Findhelp’s geolocation feature identifies nearby programs based on a member’s ZIP code, helping care teams match individuals with appropriate local services. Automated text reminders help members follow through on referrals, reducing the likelihood of care gaps that often arise from social or logistical barriers.
Integrating Clinical and Social Data for Whole-Person Care
Research shows that integrating social-risk variables such as economic stability and social context with clinical data improves the accuracy of risk prediction and supports better population health outcomes.
By bringing Findhelp into the TruCare environment, Zyter|TruCare enables a comprehensive view of each member that connects clinical history, care plans, and social interventions in one record. This unified approach allows care teams to understand not only what care is needed but also what conditions may prevent a member from accessing it.
For example, a Care Manager assisting a patient with congestive heart failure who identified food insecurity as a contributing factor to readmissions can immediately refer the member to local food programs, all without leaving the TruCare platform. That referral becomes part of the clinical record, ensuring visibility for the entire care team and supporting more effective, person-centered interventions.
Advancing Care Coordination and Health Equity
The integration of Findhelp is not only a technical enhancement but also a step forward in advancing equitable care. Social and economic conditions contribute to nearly 80 percent of health outcomes, yet they often remain disconnected from clinical workflows. By embedding social resource coordination within TruCare, this critical gap is addressed efficiently and effectively.
As Julia Jones, Vice President of Network Development at Findhelp, explained, this integration “allows healthcare organizations to streamline care coordination and address patients’ social needs directly within their existing workflows.” It is an operational shift that enables organizations to act on social data in real time rather than rely solely on retrospective reporting or external systems.
From Clinical Insight to Community Impact
For clinicians and care managers, this integration offers more than convenience. It strengthens the link between data-driven insights and actionable care. Every referral, follow-up, and community connection becomes part of a continuous feedback loop that enhances population health outcomes.
For example, integrating Findhelp enables care teams to:
- Identify social risks during assessments and act immediately within the same workflow.
- Automate documentation of referrals for compliance and quality reporting.
- Measure the impact of social interventions on utilization, cost, and outcomes.
- Collaborate more effectively across multidisciplinary teams, reducing duplication and administrative burden.
By combining clinical decision support with access to social care resources, Zyter|TruCare is helping care teams move from identifying risk to resolving it. The result is a care management model that not only treats illness but also addresses the social context in which health is lived and maintained.
A Meaningful Step Toward Whole-Person Health
The integration of Findhelp within TruCare represents a meaningful step toward whole-person care, where clinical excellence and community connection work together to improve outcomes, reduce disparities, and support healthier lives. Seamless integration of a social care network into the care management workflow will become even more important as state Medicard Rural Health Transformation programs start to roll out in 2026.
Contact us to learn how your organization can operationalize SDOH referrals within member-centric clinical workflows.
