Request for Information on Innovative Approaches to Achieving Equitable Community Health Ecosystems


The Kresge Foundation’s Health Program


This request seeks ideas and examples from those who have built or are building community health ecosystems that can inform future grantmaking, engagement, and learning strategies.

IRIS Response to Innovative Approaches RFI

Founded by the Center for Public Partnerships and Research (CPPR) at the University of Kansas, Integrated Referral Intake System (IRIS) facilitates strengthening community health ecosystems through driving change in communities ready to transform how families are connected to resources. IRIS offers a robust implementation process, leading with collaboration, trust, and accountability, that centers community stakeholders to collectively envision the future they want. The process guides community partners through design and implementation to create a coordinated referral network equipped to advance community resilience. This community-centered approach is paired with a bi-directional technology referral tool that provides a streamlined process for making, receiving, and tracking referrals between cross-sector partners. Data from the resulting social care network allows for a greater understanding of community health ecosystem strength and guides the facilitation of network sustainability.

Grounded in implementation science principles, the IRIS implementation process is the cornerstone that honors the expertise of the partners who live and work in the community by positioning local stakeholders as implementation leaders. When community stakeholders are empowered to take the lead, decisions are community-focused and data-driven, and IRIS is implemented in a manner that addresses unique local demands.

Since 2017, community leaders in six states have utilized IRIS to strengthen partnerships, increase communication and accountability, and create connections for families and children to a variety of services. The 32 IRIS networks span diverse settings – urban neighborhoods, rural communities, and multi-county collaboratives. The partners and providers that utilize IRIS reflect their network's unique vision. Behavioral health providers, coalition leaders, resource navigators, early childhood providers, health systems, and a range of community-based organizations step forward to co-create a community network that supports equity in services across their communities.
Through intentionally building networks with cross-sector partners, successful connections are continually created to address gaps and barriers in services. Information collected by IRIS communities can help improve access to care through advocacy and education to address health equity initiatives and expand community-led public health and health care system programs to advance individual and community health.

Achieving Health Equity
IRIS strives to align efforts in communities to achieve full health equity for all individuals through proven structures and processes that assist in eliminating systemic inequities in access to services, foster multi-sector collaborations rooted in accountability and transparency, and authentically engage communities to support holistic approaches to care. IRIS offers actionable data to identify barriers and address systemic challenges. This referral technology and collaborative approach creates shared responsibility across the network supported by best practices for effective referrals to available service options, clarifying eligibility requirements and potential accessibility barriers, and monitoring referral progress and loop closure.

At all levels, IRIS provides communities with the agency to define what information they collect from individuals and to dictate when, how, and through what context they leverage the data. Depending on the community's vision and needs, data might include race and ethnicity, gender, primary language, income, insurance status, etc. Reviewing this data in the context of referral outcomes allows network partners to identify referral barriers, improve partners' processes, maximize available resources' impact, and advocate for strategies to meet community needs. The connections built through IRIS enable all community partners to cultivate relationships, building a strong ecosystem to ensure families are seen, heard, and provided with quality care and resources.

While IRIS provides communities with a valuable method of streamlining referral processes and creates connections across sectors, it requires the engagement of community partners to succeed. Partners are more likely to adopt a technological solution when visionaries within a community lead the implementation process. Within the IRIS approach, these visionaries are known as community champions. These individuals are vital to all stages of the IRIS implementation process as they work to engender trusting relationships with local leaders and respond to their community's unique needs. Applying their deep knowledge of community resources and needs, community champions build nimble networks equipped to pivot to address emerging challenges and capitalize on opportunities such as implementing emergency financial assistance application processes and coordinating food delivery services for individuals impacted by COVID-19.

Community champions advance implementation with their ability to build effective community partnerships and develop the infrastructure to further the community's vision. These individuals are often ingrained in the community and possess the social relationships necessary to facilitate participation and dynamic collaborations. In many instances, these community champions are already leading existing community efforts to promote their constituents' health and well-being. Drawing on this alignment, the IRIS approach positions care managers, early childhood coordinators, pediatricians, public health administrators, and directors of community-based organizations to lead community-level implementation, building the champions' capacity through coaching, peer learning, and action roadmaps.

In building a community network of partnerships, connections are made to address health equity initiatives and expand community-led public health and health care system programs. Connected systems and supportive tools provide greater opportunities to build strong cross-sector collaborations, address social determinants of health, and optimize conditions throughout a community by creating and supporting a shared vision with focused efforts to improve quality community health ecosystems. When there are inclusive community health ecosystems, families can be connected to services through quick-response coordination and collaboration across multiple community-centered health programs.

The need for a shared referral tool is often identified by community service providers who recognize that navigating systems of care is complex, particularly for those who have been disadvantaged by policies and systems. However, the adoption and continued use of a technological tool across community organizations are challenging. To that end, community partners are more likely to adopt a technological solution when visionaries within a community lead the IRIS implementation. These individuals play a key role in understanding the unique relationships and challenges within a community but may lack the capacity built-in to current service roles and experience necessary to enact the change management associated with implementing a referral platform.

Many communities that would benefit from the IRIS platform are plagued by this and other systemic challenges that could create stress points in the implementation process – such as a lack of partner buy-in, competing priorities, and under-represented community voice. Therefore, focusing on community-led implementation while using a technology tool and network analysis to understand ecosystem growth and strength allows for continued community-champion-led facilitation to the point of network sustainability. These three elements are key to embedding health equity into community ecosystems.

Lessons Learned
The IRIS approach strengthens collaboration and communication between community partners and state-level leaders, building multi-sector networks that raise family voice and allow communities to thrive. Integrating local experts at all levels of implementation can improve existing health ecosystems by placing families first. When community champions are present, it forms the backbone of a collaborative approach necessary to construct positive outcomes. In supporting partners to take ownership of their network and prioritizing the needs of the families they serve, communities amplify the voices of partners and their constituents to shape decisions that provide equitable health and social well-being experiences and outcomes for individuals and families in their communities.


Download: Innovative Approaches to Achieving Equitable Community Health Ecosystem