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HEALR Concierge Workflow

 

Step 1: Intake & Relationship Building

 

Once a referral is received, a HEALR makes direct contact with the resident within 24–72 hours. Initial conversations are designed to build trust rather than simply “process” a case.

The HEALR:

• Listens to immediate concerns

• Identifies urgent barriers

• Assesses household stability

• Explains available supports

• Builds rapport through empathy and consistency

This process creates a personalized “Community Stability Plan” rather than a one-time transaction.

 

Step 2: Needs Assessment

 

The HEALR conducts a simplified but holistic SDOH assessment covering:

• Food access

• Transportation

• Housing stability

• Employment status

• Financial literacy

• Healthcare access

• Childcare needs

• Senior support

• Mental health/social isolation

• Technology access

• Veteran status

Assessments are entered into a centralized tracking system for coordination and measurable outcomes.

 

Step 3: Immediate Stabilization Supports

 

Based on assessed needs, the HEALR coordinates rapid stabilization services such as:

• Emergency food delivery

• Hygiene supplies

• Diapers and baby items

• Senior food boxes

• Transportation coordination

• Clothing assistance

• Utility referrals

• Clinical referrals

• Crisis support

• School support resources

Mission: AGAPE's community service model acts as a frontline stabilization hub while Bridges To Care coordinates broader systems integration and long-term pathway development.

 

Step 4: Warm Hand-Off Referrals

 

Rather than simply giving residents a phone number, HEALRs provide “warm hand-offs” by helping individuals directly connect to:

• Workforce programs

• Financial literacy coaching

• Healthcare providers

• Behavioral health services

• Veterans resources

• Housing support agencies

• Small business assistance through Launch SWPA

• Education and training opportunities

HEALRs remain involved during follow-up to increase completion rates and reduce system drop-off.

 

Community-Based Follow-Up Model

 

A major failure point in traditional systems is lack of follow-through. Bridges to Care addresses this by implementing continuous relationship-based follow-up.

HEALRs maintain regular communication through:

• Phone calls

• Home visits when appropriate

• Text messaging

• Community events

• Food delivery interactions

• Partner site engagement

This creates accountability, trust, and continuity.

 

Data Tracking & Outcome Measurement

 

ADS utilizes a centralized SDOH tracking framework to monitor:

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• Referral volume

• Response times

• Household demographics

• Service categories

• Repeat crisis indicators

• Clinical referral completion

• Food delivery frequency

• Workforce participation

• Financial literacy engagement

• Long-term stabilization indicators

 

Key performance indicators may include:

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• Reduced repeat emergency requests

• Increased healthcare engagement

• Increased employment participation

• Increased household budgeting activity

• Increased food stability

• Improved transportation access

• Resident satisfaction and trust scores

 

Why the Model Works

 

The Bridges to Care HEALR Concierge Model works because it blends:

• Trusted relationships

• Hyperlocal leadership

• Real-time responsiveness

• Community presence

• Systems coordination

• Long-term follow-up

• Dignity-centered support

 

Instead of expecting vulnerable residents to navigate fragmented systems alone, Bridges To Care brings trusted navigation directly into the community through people who already understand the neighborhood, culture, and lived realities of the residents they serve. The model transforms disconnected referrals into coordinated pathways toward stability, wellness, and economic mobility across the Mon Valley and Southwestern Pennsylvania.

 

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