Inside Durham’s Benefits Access Ecosystem: What We Learned at the Care Coordination Roundtable
When a family in Durham struggles to put food on the table, keep the lights on, or get a prescription filled, the health effects show up long before anyone reaches a doctor. That’s the heart of what our community partners call the social drivers of health — and it’s exactly what this month’s Care Coordination & Community Partnership Roundtable set out to untangle.
Resources at a glance
- Duke Office of Community Health — the hub for Duke Health’s community programs
- Benefits Enrollment Center — help with Medicare, Medicaid, SNAP, and Extra Help
- Building Healthy Communities & Partnerships — grantmaking and community collaboration
- Duke Population Health Management Office / DukeWELL — systemwide care coordination and SDOH screening
- Duke Health & Well-Being Programs — mindfulness, healthy-lifestyle, and teaching kitchen programs
- Violence Recovery Program — support for survivors of violence
- Duke-Margolis Institute for Health Policy — health policy and equity research
- Samuel DuBois Cook Center on Social Equity — research on social equity and health disparities
- Durham Housing Authority — housing and resident support
- Durham Benefits Access Coalition — the coordinating coalition for benefits access in Durham
At Breastfeed Durham, we spend a lot of time at the intersection of health, food, and family support, so we came to this virtual gathering with one question in mind: what does the benefits access ecosystem in Durham actually look like, and how do the pieces fit together? Instead of profiling the people in the room, we want to walk you through the programs — because these are the resources you can point families toward today.
Screening and referral: where it starts
Much of this work begins with a simple but powerful idea — ask people what they need, then connect them to it. Across Duke Health, case managers and social workers screen patients for social drivers of health, from food and housing insecurity to safety concerns like abuse, neglect, and intimate partner violence. Outpatient teams embedded in primary care and specialty clinics do the same, offering resource referrals and ongoing care coordination rather than a one-time handoff.
That screening only matters if there’s somewhere to refer people. So the rest of the ecosystem exists to catch what screening surfaces.
The Benefits Enrollment Center
The Benefits Enrollment Center (BEC), run through the Duke Office of Community Health, is one of the most direct front doors into public benefits. The BEC helps Medicare beneficiaries navigate enrollment and screens for eligibility across key programs — Medicaid, SNAP (food assistance), and Extra Help with Prescription Drug Costs. For a family already stretched thin, having a knowledgeable navigator makes the difference between benefits left on the table and benefits actually received.
Building Healthy Communities and food & nutrition security
Benefits enrollment is one lever; investing directly in community organizations is another. Duke’s Building Healthy Communities grantmaking program channels resources to local nonprofits and coalitions working on the ground — deepening community engagement and aligning Duke’s resources with priorities that neighborhoods identify themselves.
A major focus of that investment is food and nutrition security. Through the Food and Nutrition Strategic Council, partners work to strengthen food access across Durham — the kind of upstream support that keeps families healthier long before a clinical crisis. For breastfeeding families in particular, reliable nutrition access is foundational, so we watch this work closely.
Population health and SDOH screening at scale
Zooming out, the Duke Population Health Management Office — home to DukeWELL — is where a lot of the systemwide coordination happens. This office leads quality improvement for chronic conditions like diabetes and hypertension and serves as the physician lead for social-drivers-of-health screening and connection. The philosophy is refreshingly practical: make sure patients have everything they need — from food to education to medication — to manage their health and live fully.
Well-being, whole-person health, and teaching kitchens
Health isn’t only about filling gaps; it’s also about building strength. The Duke Health & Well-Being Programs team designs evidence-based, strengths-based programming for mind, body, spirit, emotions, and community. Their offerings range from mindfulness programs to multi-week group healthy-lifestyle programs — and, beginning in September 2026, a range of teaching kitchen programs. For a community that cares deeply about food as medicine, teaching kitchens are a resource worth keeping on your radar.
The emergency department as an upstream platform
One of the more forward-thinking ideas we heard treats the emergency department not just as a place for acute care, but as a platform for upstream intervention. That framing connects the ED to programs like DukeWELL and the Duke University Hospital Violence Recovery Program, which supports survivors of violence through recovery. This work is also informed by research and policy partners including the Duke-Margolis Institute for Health Policy and the Samuel DuBois Cook Center on Social Equity, both of which study health disparities and the social determinants of health.
Community Health Workers and housing transitions
Some of the most human-scale work happens block by block. Community Health Workers are partnering with the Durham Housing Authority to support residents recently relocated from downtown public housing. Their job is to make sure people don’t fall through the cracks during a move — ensuring residents stay enrolled in health coverage and can actually reach primary and specialty care in their new neighborhoods.
The Durham Benefits Access Coalition: tying it together
If there’s a connective thread running through all of this, it’s the Durham Benefits Access Coalition (DBAC). Established by Durham County and City leadership, DBAC coordinates efforts across health systems, government, and community organizations to help residents access the benefits they’re eligible for. Duke’s Office of Community Health works alongside DBAC to align and improve its benefit-access efforts — so that a family screened in one place can be reliably connected everywhere else.
Breastfeed Durham is proud to be part of this coalition, because we see every day how benefits access and family health are inseparable.
And students, too
Woven throughout these programs is a role for students. Duke students support benefit access and health-related social needs through community-based programs, service partnerships, and coordinated referrals — bringing energy and capacity to the work while learning what real community health looks like.
Why this matters for Durham families
What struck us most about this roundtable is how intentionally these programs are being stitched together. Screening finds the need. The Benefits Enrollment Center, Community Health Workers, and case management teams meet it. Building Healthy Communities grants, food and nutrition security work, well-being programs, and teaching kitchens build long-term resilience. And the Durham Benefits Access Coalition keeps everyone rowing in the same direction.
For the families we serve, that coordination is everything. A parent shouldn’t have to navigate a dozen disconnected systems while caring for a newborn. The more these programs work as one ecosystem, the closer we get to a Durham where every family has what it needs to thrive.
Click here, if you are Interested in getting involved with the Durham Benefits Access Coalition or learning more about how benefits access supports breastfeeding families.