At Advocates for Justice and Education (AJE), our direct services teams serve thousands of DC families of children and youth with disabilities and special health care needs (CYSHCN) on an annual basis. Families often express to AJE peer support and legal staff similar challenges while navigating important social safety net services, which can often feel like finding a path through a maze.

A family may need support from a pediatrician, a school team, a behavioral health provider, an early intervention specialist, a managed care organization, a housing support program, or a workforce development agency. Often all at the same time. Yet the DC systems of care frequently operate independently in silos, leaving parents and caregivers to coordinate services on their own or to repeat traumatic experiences over and again to different service providers in order to obtain services. And sadly, these required services are often delayed, denied, or referred out, if services are provided at all.

AJE believes families should not have to navigate these systems alone.

That is why our Health Justice Project is leading a growing community network mapping initiative designed to strengthen connections among organizations, improve warm referrals, and create a more coordinated system of support for children, youth, and families across Washington, DC.

What Is Network Mapping?

Network mapping is a community-driven process that helps identify organizations, programs, services, and relationships that support families throughout different stages of life.

Our approach focuses on understanding:

• Who is serving children, youth, and families across DC;
• Where gaps in services and referrals exist;
• How organizations currently collaborate;
• What barriers do families encounter when moving between systems, and
• How community partners can work together to create stronger pathways to care.

The goal is not simply to create a directory of resources. The goal is to cultivate professional peer relationships that make referrals more effective, more personal, and more successful.

Why This Work Matters

AJE’s Health Justice Project emerged from years of our direct services teams listening to families and recognizing that many of the challenges that  face in education advocacy are connected to broader issues in health care access in schools and in community-based settings, including the home. Our initial assessment conducted in 2023, also discovered that families also greatly struggle with receiving timely and accurate diagnoses, accessing behavioral health services, and receiving comprehensive social supports, particularly in the home setting.

Our community needs assessment led alongside AJE Parent Ambassadors, also identified several recurring concerns of DC families:

• Health care providers are not always prepared to support children and youth with disabilities and special health care needs;
• Language access and cultural responsiveness are key barriers to accessing care; and
• Essential services are frequently difficult to access due to reliable and affordable transportation barriers, long waitlists, or geographic inequities.

These findings reinforced what many families already knew: systems of care are often fragmented, creating unnecessary stress and delays in accessing support.

The Community Health Advisory Panel (CHAP)

To address these challenges, AJE established the Community Health Advisory Panel (CHAP), a cross-sector collaborative that brings together parents, caregivers, advocates, health care providers, managed care organizations, government agencies, hospitals, researchers, and community-based organizations.

CHAP serves as the backbone of AJE’s network mapping work.

Participants currently include representatives from:

• Children’s National Hospital
• Mary’s Center
• Briya Public Charter School
• AmeriHealth Caritas
• Health Services for Children with Special Needs (HSCSN)
• MedStar Family Choice
• DC Health
• DC Department of Health Care Finance
• DC Department on Disability Services
• Children’s Law Center
• George Washington University
• The Center For Health and Health Care in Schools, Milken Institute School of Public Health
• Howard University
• Bright Beginnings
• Help Me Grow
• Quality Trust
• First Shift Justice Project
• Total Family Care Coalition
• Mayor’s Office of Deaf, DeafBlind, & Hard of Hearing (MODDHH)
• DC Public Library

and many other community-based providers and advocates working to improve outcomes for DC families.

Together, CHAP members are helping identify service gaps, strengthen partnerships, and develop a coordinated warm referral network.

Centering Family Leadership

One of the most important aspects of this work is that it is guided by DC families, with targeted representation from the high impact and low access areas of Wards 1, 4, 5, 7, and 8.

AJE’s Parent Ambassador Program has been a cornerstone of our leadership development efforts since 2019. Parent Ambassadors bring lived expertise, helping shape programs, identify barriers, and inform systems change efforts across education, health care, and community services.

Today, Parent Ambassadors help co-facilitate CHAP meetings, participate in community health leadership activities, host Parent Cafés, and contribute to AJE’s ongoing quality improvement efforts.

Their experiences help ensure that network mapping remains grounded in the realities families face every day.

Moving Toward Warm Referrals

AJE’s vision extends beyond identifying organizations.

We are working toward the development of a warm referral network, which is a network of organizations actively collaborating to connect families to trusted partners rather than simply providing contact information.

Warm referrals can help:

• Reduce family stress;
• Improve follow-through on referrals;
• Increase access to services;
• Strengthen trust between families and providers;
• Improve transitions between systems;
• Support earlier identification of developmental and health needs; and
• Create more coordinated care for children and youth with disabilities and special health care needs.

As this effort grows, AJE plans to work with partners to develop referral pathways, shared workflows, continuous quality improvement processes, and stronger accountability mechanisms that help families receive the services they need.

Looking Ahead

Over the next several years, AJE envisions a stronger, more connected network of organizations serving children and youth from birth through age 26.

Through network mapping, leadership development, community engagement, and warm referral partnerships, we hope to:

• Reduce family caregiver stress;
• Increase early identification and intervention opportunities;
• Improve access to health care and behavioral health services;
• Strengthen transition supports across developmental stages;
• Improve collaboration among providers and agencies; and
• Build a more equitable and responsive system of care for DC families.

Join the Movement

AJE’s Health Justice Project is actively seeking new partners to help expand this vision.

We welcome:

• Community-based organizations
• Health care providers
• Hospitals and health systems
• Managed care organizations
• Educational institutions
• Government agencies
• Researchers and evaluation partners
• Parent and caregiver leaders
• Advocacy organizations
• Philanthropic and funding partners

If your organization is interested in participating in AJE’s network mapping, joining CHAP, support the warm referral development, collaborate on family leadership initiatives, or invest in sustainable systems change, we would love to hear from you.

To learn more, partner with us, or explore funding opportunities, please contact: advocacy@aje-dc.org

Together, we can build stronger connections, reduce barriers, and create healthier futures for children, youth, and families across the District of Columbia.