Priority Program
The Community HUB: Scaling Social-Health Integration
"The baseline problem with social screening is that a referral is not an intervention. True health equity occurs when the loop is physically closed at the kitchen table."
The Core Framework
Centralized Administration
TransitionWell holds the top-tier commercial insurance vendor contracts, removing the heavy burden of insurance billing and data compliance from local non-profits.
Smart Form Triage
We utilize a 2-tier smart screener to filter health plan referrals, protecting frontline staff capacity and focusing resources strictly on members facing active crises.
Verified Delivery
We require hard verification to close a pathway—meaning the medication bubble-packs are on the counter, the SNAP benefits are active, and the grab bars are securely bolted to the wall.
Build Sustainability for Your Existing CHW Workforce
We partner with regional Area Agencies on Aging and senior networks under a transparent 75/25 financial split. We handle the technology, contracts, and invoicing; you deploy your trusted, certified CHWs and capture predictable commercial revenue.
Request a Regional AAA Consultation"We close the loop—not when the referral is made, but when the outcome is verified."