Published 3/5/2025 | Written by Bob Proehl

Public health is not achieved simply by ensuring there are enough doctors to provide services in a community. To support community wellbeing, unmet social needs that prevent access to care must also be addressed. “Lack of transportation, lack of internet and computer access, high cost and limited availability of childcare, and the lack of services outside typical work hours are all barriers to care,” says Nicole Zulu, Director of Health Planning for the Human Services Coalition of Tompkins County. “This is especially true in rural areas.”

Even when organizations exist to help meet these needs, it can be challenging for both doctors making referrals and community members seeking assistance to identify the array of services available. “Community members who need support often feel overwhelmed trying to understand the full landscape of what programs exist, who‘s eligible, and how to connect,” says Grace Parker Zielinski, Community Health Coordinator for Cornell Cooperative Extension.

In Tompkins County, many of these community-based organizations were aware of each other’s efforts but lacked a system to effectively coordinate their work. “We often say we‘re resource-rich but systems-poor in our community,” says Parker Zielinski. “Without good systems, we have a hard time providing equitable care or even understanding what the next steps to increase equity might be.”

At the time, Cornell Public Health Professor of Practice, Dr. Karla Hanson and Visiting Lecturer, Lara Parrilla were already exploring this issue and had recently co-developed the course “Cross-Sector Collaborations to Improve Health Equity.” Their class, full of public health, health administration, and undergraduate students were eager to help. Together, the students explored coordinated health and social care through hands-on learning and found that there was strong support for more coordinated care, but a deep sense of disconnect between organizations.

In 2023, Cayuga Health—the leading healthcare provider in Tompkins County—received $7.7 million dollars in New York State funding to develop a local Community Health & Resource Network to enable social care providers to seamlessly receive and send referrals across organizations and providers. An initial cohort of 15 local organizations helped develop the Network, and now those same organizations are testing its efficacy. “Cornell Public Health has contributed to the process from the beginning,” says Zulu. “They helped us think through what elements to incorporate for meetings and breakout sessions to ensure pertinent information is collected and biases are limited.”

“Working with Karla‘s class also helped us think concretely about how to measure and demonstrate program impacts that are relevant to multiple audiences,” adds Parker Zielinski. “And they completed formative evaluations to ensure we‘re continually improving processes to maximize our impact.”

Cornell Public Health continues to monitor the roll-out of the Network, provide on-going feedback to Network members, and co-develop recommendations for improvements. “It has been wonderful having Karla and her students provide this monitoring and evaluation,” notes Zulu. The Network is now in a moment of assessment and expansion. There are still more providers in Tompkins County that need to be added to the Network, while expansion to other counties is being explored.

Data from the Network will also be used to identify social needs for which there are not adequate local resources, to support growth in these areas. “The feedback loops the Network creates will allow us to get a more global understanding of who we‘re reaching and not reaching,” reflects Parker Zielinski, “and how we can make the best use of our collective resources to fill persistent gaps.”