Bridging Community Food Insecurity Gaps through Care Coordination

Quantitatively, we have seen an increase in referrals for food insecurity through the Connected Care community health worker program as a result of improved coordination with MCHHS discharge planning and strengthened community partnerships. At a minimum, 150 individuals were directly impacted during this short project period (August-November), with many more expected to continue benefiting as these partnerships, referral pathways, and systems remain in place.

Qualitatively, feedback from both partners and clients highlights the value of clearer referral processes and trusted, relationship-based support. Community partners report improved communication, reduced duplication of services, and greater awareness of available resources and service gaps. Clients have shared that having a single, trusted point of contact helps reduce confusion, stigma, and barriers to accessing food assistance—particularly in a rural setting where privacy and trust are significant considerations.

Together, these quantitative outcomes and qualitative insights demonstrate meaningful progress toward a more coordinated, sustainable, and community-responsive approach to addressing food insecurity in Mitchell County.