20 MONTEREY COUNTY WEEKLY NOVEMBER 13-19, 2025 www.montereycountynow.com Health, pulling out and instead opting to develop its own system. Madfis has tried unsuccessfully to recruit CCAH back into the fold. “Building a parallel [community information exchange] risks undermining—not strengthening—our collective impact,” he wrote in an email to CCAH officials in August.) The decrease in usage is why Madfis is presenting to the Children’s Council in October, urging this group to utilize the Smart Referral Network. “In the course of your career, you have your rolodex of referral relationships,” Madfis says. “But when you go, that rolodex goes with you. I am trying to institutionalize those relationships. Where we are going with this is better access to client data, and better coordination among service providers.” The logic is that the more agencies are involved, offering portals to more programs, the more effective it is. “Using this referral software is real systems change,” Madfis told the Children’s Policy Council on Oct. 13. “We need systems leaders to adopt it.” Despite our technology-oriented world, technology is relatively new to the realm of community-based organizations where people still talk about rolodexes. After a 37-year career in tech, with time at the likes of Microsoft, Amazon and IBM, David McCann is now semi-retired, working as chief technology office for United Ways of California from his home in Orange County. “We as humans are journeying through the most rapid era of digital transformation we’ve ever done,” he observes. “I buy my airline tickets on Expedia, I listen to music on Spotify, I bank from my phone. Everybody is having to modernize. The last people to do it are community-based organizations. It’s the last part of society that hasn’t modernized the way they handle data. Really, CBOs are late to the party.” They are arriving at the party now, with the Smart Referral Network developed by Madfis—which is now also licensed to United Way chapters in Tulare County and Kings County— and a similar system developed in Orange County called Get Help, now deployed in Orange, Riverside and San Bernardino counties. “Monterey is on the leading edge,” McCann says. This is in part driven by people like Madfis and McCann, and the hundreds of case managers they work with. It’s also driven by the State of California. “Agencies are frustrated as hell,” McCann says. “Everybody is saying, we are spending a lot of money, but we are not getting outcomes. We need to use the taxpayer dollar better to coordinate social care so we get a better return.” In 2021, Assembly Bill 133 was signed into law, an omnibus trailer health bill bringing a new vision to how various health programs in California are administered, tracked and compensated. The legislation established an initiative called CalAIM, charging the California Department of Health Care Services with reenvisioning how Medi-Cal (the state version of Medicaid) is delivered, seeking to focus on preventive and holistic interventions. The legislation also tasked the California Health and Human Services Department with developing the Data Exchange Framework (DxF), in which social services agencies and medical providers share data—a lot like the tools United Ways are utilizing, with a focus on medical providers. AB 133 led to $47 million in state grants to organizations to implement these goals, including a $475,000 grant to nine United Way chapters (Monterey County’s among them). The state funding unlocked fundraising potential for development and enhancement of local-level systems. McCann estimates about 75 percent of funding comes from government, the rest from philanthropy. “We are not a for-profit software company,” he notes. There’s pressure—and now funding—from government to transition to a modern referral system. But perhaps the most significant driver is the case managers who are actually using the Smart Referral Network or similar systems day-to-day. I magine the situation for a case worker at one of the 90 local organizations that has signed on to use the Smart Referral Network, where thousands of clients show up in various stages of crisis. At Sun Street Centers, a nonprofit that focuses on substance abuse prevention and treatment, the focus of a client is usually on the problem immediately in front of them. “We spend about an hour-and-ahalf with someone. Maybe they need food stamps, maybe they need some kind of supportive living, maybe they need dental care,” Sun Street Centers’ CEO Anna Foglia says. “But people are not thinking about referrals in that moment.” That moment for some clients is that they’ve been picked up and dropped off by police at Sun Street’s sobering center; it’s hard to follow through on anything besides what is immediately in front of them. The old-fashioned way of handling referrals for those clients is to hand them a piece of paper that they can use, if they remember to. Using the Smart Referral Network, a case worker can quickly click through and tag all of the agencies and programs that a client might be interested in, generating a notification to those other agencies to call the client and follow up, instead of expecting the client to do so. George Myers doesn’t think he would have ever followed up on a referral on his own—he can’t imagine keeping track of such a piece of paper. But now, as he prepares to graduate on Nov. 21 from a three-month residential sobriety program at Sun Street, he’s already set up with a range of services. He’s on the waiting list for Section 8 housing, he’s getting psychiatric care and dental work, plus discounted bus passes so he can get to his new job. “My options are very wide now, where I had none before,” Myers says. “It is all going to work out for me, I’m sure.” Myers did not walk into Sun Street Centers looking for housing or dental care. He came in looking to quit drugs. But having a home has been transformational. “I just don’t want to go back to being homeless,” he says. “Homeless is a very hard spot for an addict.” Myers has been addicted to drugs since he was 13 years old. Now 51, he’s sober and employed for the first time in his life, and has aspirations for a career. He can’t get a driver’s license yet—but one of his referrals is to get help clearing DUIs on his record so he can. And once that happens, he dreams of getting licensed to become a truck driver. (“Why not travel?” he says.) This idea of having a dream at all is new to Myers. He has been homeless for years, and spent eight years in prison. Through his sponsor he got connected to a plumber, who hired him to dig holes for new pipe at a project in Prunedale. “I don’t complain about the work, because it’s something new,” Myers says. “I proved myself. I can look in the George Myers, right, with his case manager, Fatima Torres, at Sun Street Centers. “The structure here is awesome,” Myers says. “They have been through it, they are not by a book. It makes us feel like we can do it. They make you feel really comfortable—I feel loved.” “My options are very wide now, where I had none before.” DANIEL DREIFUSS
RkJQdWJsaXNoZXIy MjAzNjQ1NQ==