Now more than ever, providers are seeing the impact of social determinants of health on patient outcomes — but it’s something that most healthcare professionals aren’t trained on how to solve. New CMS health equity requirements will require providers to show how they’re addressing health-related social needs and how they are incorporating that strategy into their work. This requirement represents a huge opportunity to improve patient outcomes at scale but also introduces many open questions on how to do so. 

Here’s the good news – you don’t have to figure it out alone. Join us for a free webinar on how to address patients’ SDoH needs through social care screenings, personalized resources, closed-loop referrals, and robust outcomes tracking. 

During this webinar, you will:

• Understand how to make better use of screening data to address SDoH needs.  
• Learn how other organizations like yours have measured and reported on health equity goals and progress. 
• Gain insight into how to leverage technology tools across the enterprise so that you can focus on what you do best: providing the best possible care to your patients.  
• And more!

The post Screen, Refer, Resolve: A Toolkit for Addressing Patients’ SDOH Needs appeared first on uniteus.com.

Introduction

It is well documented that social drivers of health (SDOH) contribute to a person’s health, well-being, and quality of life and that unmet social needs contribute to health disparities, especially among vulnerable populations. The healthcare industry and regulatory environment continue to advance value-based payment models, with increasing emphasis on primary and longitudinal services to address chronic and communicable diseases and their associated healthcare costs, in an effort to improve health equity. 

Given the substantial evidence base tying unmet social needs (e.g., food, housing, transportation, social connection) to poorer health outcomes and higher healthcare costs, it is no surprise that the shift to quality care has ushered forth renewed energy across sectors to resolve those unmet needs that may be impacting health. Addressing social needs may require providers and systems to change their documentation practices and lean into community services and partnerships. Providing this type of “person-centered” quality care will require building bridges and closed-loop infrastructure between the health and social sectors to allow for seamless patient referrals, social care navigation, documentation of outcomes, and reimbursement. 

In this article, we review the current literature pertaining to social care and quality outcomes, provide a case example, and follow up with recommendations for assessing and addressing the diverse spectrum of social care needs. We believe that by adopting this approach to inclusive health care and de-siloing health and social services, we move toward true quality care. When we do this at scale, quality care will become equitable care and equitable care, quality care.

Healthcare Stakeholders Recognize the Role of Social Drivers of Health (SDOH)

Before social needs can be addressed, they must first be assessed. National organizations such as the National Committee for Quality Assurance (NCQA), Joint Commission, National Quality Forum (NQF), American Hospital Association and at least 28 states recommend or require social need screening, with 17 states requiring uniform SDOH questions within screening tools. Social need measures are currently included or proposed to be included in at least 18 CMS programs, initiatives, or federal guidance. Beginning in 2024, the Centers for Medicare and Medicaid Services (CMS) will require hospitals reporting to the Inpatient Quality Reporting program to submit two brand new measures: SDOH-1 (Of all the patients admitted to the hospital, how many were screened for SDOH?) and SDOH-2 (How many were identified as having one or more social risk factor?).

In advance of specific recommendations and regulations, healthcare stakeholders have already recognized that implementation of interventions to identify and address SDOH is one mechanism to improve the quality of care and deliver better outcomes. From 2017 to 2019, fifty-seven health systems in the U.S. publicly announced investments of approximately $2.5 billion toward addressing SDOH including housing, food security, and job training. Additionally, analysis of a 2021 national hospital survey demonstrated that more than 75% of acute care hospitals already screen for health-related social needs. 

 Health plans too are recognizing the importance of addressing SDOH by working to expand information exchange and establishing partnerships with community-based organizations (CBOs), especially in light of recent Medicare Advantage policy changes (i.e., supplemental benefits that are not primarily health-related). For example, from 2023-2023, Horizon Blue Cross Blue Shield of New Jersey operated one of the largest programs, Horizon Neighbors in Health, to address SDOH in the state of New Jersey. The Neighbors in Health program utilized community health workers and personal health assistants to improve the health and well-being of individuals across 21 counties. By the summer of 2023, the program had enrolled over 13,000 members and had met the social needs of 8,000 individuals. The success of the program led Horizon to integrate the approach into its larger care management program and increase screening of and engagement with members who have SDOH needs.

The Impact of Social Care on Quality Outcomes 

Healthcare systems, payers, and others are understandably eager for additional rigorous evidence showing that addressing social care needs can measurably improve health outcomes and reduce unnecessary spending. While longer-term outcomes are important, quality measures such as preventive screenings, engagement with primary care, medication adherence, and satisfaction with care can serve as more proximal measures for the impact of addressing social needs. Improvements in these process measures may be a signal that social needs are being addressed. 

Results from a retrospective, cross-sectional analysis of 7,995 individuals found that those with transportation vulnerability were significantly less likely to be vaccinated against influenza. A study examining the relationship between cancer screening completion and receipt of government housing assistance among low-income adults found that housing assistance facilitated increased breast cancer screening among certain subgroups (with odds of mammography completion increasing more than two-fold for Hispanic and younger women). Another cohort study of 6,692 antihypertensive medication users found that receipt of Supplemental Nutrition Assistance Program benefits was associated with a nearly 14-percentage point reduction in medication nonadherence among food-insecure patients. Importantly, interventions that help individuals address social needs (e.g., via connection to community-based resources) have been linked to improved patient satisfaction. In one national study of nonelderly Medicaid managed care enrollees, those who received social needs assistance (e.g., transportation, food, housing) rated perceived quality of care as “the best” compared to those who did not receive social needs assistance. Two other nationally representative patient satisfaction surveys indicated that patients perceived they were “better cared for” and had more trust in their provider or health system when screened for social risks. 

Finally, results from the Accountable Health Communities model, which systematically tested the impact of screening and navigation interventions to resolve health-related social needs of publicly-insured individuals, show reduced emergency department visits among Medicaid and fee-for-service Medicare beneficiaries compared to matched controls. The reduction, especially for Medicare beneficiaries, was driven largely by avoidable healthcare use, suggesting social care navigation may impact beneficiary behavior that fundamentally alters the type of healthcare used. Additional insights shared directly from one model participant highlight the value of screening and referral work for both providers and patients alike, and the importance of “closing the loop” and reimbursing community partners for their important role. 

Case Study: Insights from Scaling Social Needs Screening Workflows Across New Mexico

One highly successful example of a universal social needs screening program is Presbyterian Healthcare Services. In the fall of 2021, Presbyterian Healthcare Services implemented universal social needs screening to ensure all patients with a clinical encounter within the delivery system were screened at least every six months to identify social needs in the areas of food, housing, transportation, utilities, substance/alcohol/tobacco use, possible depression, and interpersonal safety. Presbyterian’s IT and Clinical Informatics teams were engaged to identify optimal workflows and leverage SDOH functionalities within its Electronic Medical Records (EMR) system. In ambulatory and inpatient settings, screening was integrated into the rooming process, while in emergency department settings it was added to the secondary triage workflow. 

The project team focused on automating the screening process by configuring pop-up messages to alert rooming and triage teams when screening questions were due to be asked, and adding the questions to the eCheck-in process to give patients the option to self-screen through their patient portal. If a social need is identified during screening, an automated process initiates within the EMR and an integrated cross-sector collaboration software (Unite Us) generates a personalized list of community services delivered directly to the patient’s after-visit summary. Since the launch of universal screening, Presbyterian Healthcare Services has conducted more than 2.8 million screenings, identifying and providing community resources for more than 250,000 social needs.

While identification of social needs is a critical step, improving clinical outcomes will require acting on those social needs through SDOH interventions, including follow-up to determine if the need was resolved. As Leigh Caswell, Vice President of Community and Health Equity at Presbyterian Healthcare Services states, 

“Scaling and sustaining the social care navigation infrastructure has been a challenge because we’ve learned a referral to a social service isn’t enough; there needs to be navigation through community health workers, social workers, and/or peer support specialists to community resources and follow-up to support patients through the barriers faced while navigating these systems. With innovative value-based payment models and Medicaid 1115 waivers, these types of social care navigators and social service resources are becoming more accessible and sustainable, incorporating funding for these services including direct payment for food prescription programs and reimbursement for community health workers.” 

In 2024, Presbyterian will utilize a closed-loop referral system through Unite Us that will facilitate referrals directly to CBOs on behalf of Presbyterian patients, and provide visibility into the community care delivered, until an outcome or resolution is documented for the patient’s social need. Using metrics that track not only if screening occurred and if a referral was made, but also how long it takes the referral to be accepted by a partner—and ultimately the specific outcome of the referral—will enable better understanding of where additional investment is needed in the community to ensure appropriate capacity of social services to address needs. 

Standardization in Social Needs Measurement: A Key to Meaningful Data 

The standardization of measures involves a nuanced approach that extends from aligning data elements within specific measures, with a focus on screening and intervention terminology, to establishing a coherent standardization across the broader SDOH ecosystem. This comprehensive effort not only harmonizes the granularity of data elements needed to screen for social needs, but also addresses the need for uniform metrics across the healthcare system. To access valuable data, standardization ensures meaningful comparisons of population health outcomes, contributing significantly to the goal of reducing health disparities, especially for underserved communities. Nationally, work is being done to ensure alignment among social needs measures, with a commitment to create a unified and interoperable framework for robust analysis and informed decision-making for all stakeholders. Five fundamental domains, encompassing aspects of food insecurity, housing instability, transportation needs, utility insecurity, and interpersonal safety, have been recognized across national and state-level programs and initiatives. As the industry begins to incorporate social care data into standard practice, care should be taken to utilize standard and validated tools to evaluate impact on quality of care.

In February 2023, NCQA, the Joint Commission and NQF released a joint statement recognizing the importance of using a Fast Healthcare Interoperability Resources (FHIR)-based approach to meet the social needs of individuals in the healthcare system. The FHIR Questionnaire and Questionnaire Response profile enables the exchange of findings on standardized instruments, which can be measured and trended at the individual level. This person-reported information will be valuable for improving quality and equity at the population health level. By incorporating standardized data elements, we can more accurately compare outcomes across organizations and industries. 

In Measurement Year (MY) 2023, NCQA published their Social Needs Screening and Intervention measure in the Healthcare Effectiveness Data and Information Set (HEDIS®) to assess, quantify, and evaluate the performance of social needs screening at interventions at the health plan level. NCQA’s primary emphasis has centered on tackling unmet social needs in the domains of food, housing, and transportation through the ongoing implementation of Social Needs Screening and Intervention measure, which was released in HEDIS Measurement Year (MY) 2023. First year analysis, scheduled for the summer of 2024, promises valuable insights into the effectiveness of utilizing current Logical Observation Identifiers Names and Codes (LOINC®)-based terminology for capturing social need screenings. Furthermore, this evaluation will play a pivotal role in determining the seamless integration of CMS’s recent recommendations, as outlined in the Physician Fee Schedule for 2024. This includes exploring the incorporation of additional SDOH data, such as ICD-10 Z codes, into the existing landscape of social needs measurement. 

Another critical component to addressing social needs is data stratification that captures and respects the diversity of the U.S. population including race, ethnicity, language, or disability (REALD) as well as sexual orientation or gender identity (SOGI). For example, CMS recommends states implement stratification in the Medicaid Home and Community Based Services Quality Measure Set and the Hospital Readmissions Reduction Program, and NCQA required race and ethnicity stratification for 5 HEDIS measures in measurement starting in 2022. These data categories can be used to create more detailed and meaningful stratification for quality performance measurement, which must not be overlooked as we continue to understand differences in SDOH outcomes among subpopulations. 

Looking Forward

We are at a pivotal moment where multiple sectors are more motivated than ever to address SDOH, eliminate healthcare disparities, and measurably improve the lives of the individuals they serve. In communities across the U.S., health systems, payers, government agencies, CBOs, and others are working more closely together to assess social needs, address identified concerns, document the outcome of assistance received, and, increasingly, provide financial reimbursement for services rendered. This cross-sector collaboration is driven, in part, by the fundamental belief that addressing health-related social needs is core to providing high-quality, equitable, and whole-person-centered care. As screening for social needs becomes even more commonplace, it is imperative that organizations proactively consider the “so what” should a need be identified. To do this effectively, we are calling for a paradigm shift that recognizes community-based services like food assistance, housing support, and transportation, as equal partners in the care continuum. We encourage early and sustained engagement of CBOs, as well as patients, in the design, implementation, and evaluation of interventions to assess and address social needs. 

 ¹HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post The Foundational First Step in Achieving Quality Care: Assessing and Addressing the Diverse Spectrum of Social Care Needs appeared first on uniteus.com.

Unite Us experts and industry partner, Media Logic, unveil exclusive research findings on 2024 Annual Enrollment Period (AEP) results and impactful customer lessons for your growth and retention strategies ahead.
2023 provided another challenging landscape for AEP with economic uncertainty, international turmoil, shifting consumer attitudes, and slowed MA growth – all leading up to an impending election year ahead. These factors highlight the importance of the art and science of a granular understanding of market dynamics, competitor strategies, and opportunities for growth when developing a holistic marketing approach to attract and retain members in a competitive market.

Unite Us Insights Growth product has enabled our customers to outperform the industry average in 2024 AEP for the sixth straight year. Together with Media Logic, this webinar will help health plans quickly understand key trends from AEP results and develop more clarity around market dynamics to drive future decisions on product design, business development, and marketing and engagement strategies.

You will learn about:

• Competitive factors influencing National and Regional plan performance in 2024
• Emerging trends on industry, consumer behaviors, and preferences
• Strategies for crafting effective and local Medicare marketing campaigns to stand out from National competitors
• How to gain and retain Medicare members for upcoming 2025 AEP

The post Own Your Medicare Market: Lessons Learned and Winning Strategies for AEP 2024 appeared first on uniteus.com.

Now more than ever, providers are seeing the impact of social determinants of health on patient outcomes — but it’s something that most healthcare professionals aren’t trained on how to solve. New CMS health equity requirements will require providers to show how they’re addressing health-related social needs and how they are incorporating that strategy into their work. This requirement represents a huge opportunity to improve patient outcomes at scale but also introduces many open questions on how to do so.

Here’s the good news – you don’t have to figure it out alone. Join us for a free webinar with Nicole Harris-Hollingsworth, Vice President, Social Determinants of Health at Hackensack Meridian Health, Angela Schubert, Senior Business Analyst at BJC, and Gillian Feldmeth, Director of Research and Evaluation Operations at Unite Us, in a discussion on the benefits of automation and integration when providing whole-person care.

During this webinar, you will:

• Understand how to make better use of screening data to address SDoH needs.
• Learn how other organizations like yours have measured and reported on health equity goals and progress.
• Gain insight into how to leverage technology tools across the enterprise so that you can focus on what you do best: providing the best possible care to your patients.
• And more!

The post Achieving Whole-Person Care with Automation and Integration appeared first on uniteus.com.

As the market leader in empowering care coordination, Unite Us has witnessed many of the challenges that individuals face when seeking services across siloed providers, as well as the difficulties that Part 2 providers manage when working to coordinate care with their partners. The final rule aims to address those challenges by aligning Part 2 with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), thereby facilitating integration of SUD treatment information with other health information. In this way, the final rule will help enhance providers’ ability to treat the whole person and improve health outcomes, while continuing to protect the privacy of those seeking care.

In a letter to the Office of Civil Rights on a proposed version of the rule, Unite Us wrote: “Individuals with SUDs deserve equal access to coordinated networks of care to improve their health and well-being. Integrated whole-person care, which is critical for an individual’s health and well-being, requires that providers be able to share clinical information about the client’s treatment and their healthcare condition.” You can read Unite Us’s full comment letter here.

Read the Comment Letter

The post Unite Us Applauds HHS for Advancing Care Coordination and Improving Outcomes for Individuals with Substance Use Disorders appeared first on uniteus.com.

CalAIM is California’s groundbreaking effort to improve the lives of the Medi-Cal population by meeting people where they are, addressing social drivers of health, and breaking down barriers in accessing care. This population health approach prioritizes prevention and whole-person care. 

An Opportunity for Joint Innovation

To navigate this dynamic environment and deliver comprehensive care to vulnerable populations, health plans need innovative solutions that go beyond traditional healthcare delivery services. That’s where Unite Us comes in.

CalAIM recognizes the need for a broader delivery system, program, and payment reform across the Medi-Cal program, making collaboration and coordination across sectors essential to address complex challenges such as homelessness, behavioral health care access, and the needs of justice-involved populations. Since Unite Us’ launch in 2013, we have established an industry standard for social care coordination. With best practices ensuring that people receive the care they need and accountable networks in every county, we are on the ground in California to meet the needs of health plans and the communities they serve to meet the state’s ambitious goals for population health.

For health plans and community organizations alike, ease of use is top of mind. We connect clinical and community organizations, delivering an intuitive coordination experience and reducing the risk of errors and inefficiencies, thanks to integrated workflows and tools: from screenings and eligibility to referrals and follow-ups. Our secure infrastructure for information exchange allows for a single member record and an integrated view across medical and non-medical services so as to enable non-duplicative, member-centered care across multiple touchpoints. A Unite Us partner at Florida health system identified 3.97 hours saved per case manager per week, resulting in an annual cost savings of $7,225 per case manager in a research and evaluation study.

Unite Us is the only vendor that has built a responsive and accountable social care network across California that provides real-time connectivity—supporting the upcoming DHCS requirement for a closed-loop referral system. We’ve partnered with population health management organizations, such as county agencies and community-based organizations, to help health plans swiftly contract and onboard community partners ready to serve your members. Our continuous training and user engagement ensure adoption and appropriate utilization. We support partners in achieving their goals and monitor network activities to understand how population needs evolve. 

Identifying Social Needs and Connecting People to Services

Unite Us provides a powerful interoperable platform that makes it easy to screen for social needs, identify the most suitable resources, and securely connect individuals to the services that can make a difference in their lives. In a fragmented healthcare landscape where individuals may need access to multiple delivery systems, Unite Us streamlines the process, ensuring that people receive holistic care.

CalAIM seeks to identify and manage member risk and needs through whole-person care approaches and addressing social determinants of health. Within CalAIM, Enhanced Care Management (ECM) and Community Supports (CS) are foundational parts of the transformation focused on:

• Breaking down the traditional walls of health care, extending beyond hospitals and health care settings into communities; 
• Introducing a better way to coordinate care; and
• Providing high-need members with in-person care management where they live.

This aligns with Unite Us’ mission to connect communities and improve well-being by addressing social needs and disparities. By leveraging the Unite Us Platform and network, ECM and CS partners across California are securely making closed-loop referrals without manual or duplicative efforts. 

Data-Driven Impact Measurement

Building healthier communities requires more than just addressing immediate challenges. It demands a data-driven approach to understand what works, what doesn’t, and how to scale impact across providers and networks. Unite Us offers our Platform and Insights Center as tools for health plans to comprehensively understand the members’ needs and outcomes of care delivery. 

CalAIM aims to track, in real-time, the impact of reducing disparities and improving health outcomes. With Unite Us, health plans can achieve this goal by measuring the effectiveness of their social care strategy and developing a data-driven population health management strategy. Unite Us’ data offerings include:

• The ability to standardize social care information, with over 700 referral and service outcomes to understand gaps and opportunities and ensure investments are working
• Secure information exchange infrastructure that is HIPAA-compliant and HITRUST, NIST, and SOC-2 certified
• Data-driven insights to proactively identify social care needs, as well as communication preferences to support enrollment into Enhanced Care Management and Community Supports Services

To avoid duplicative data entry and managing multiple data systems across settings, Unite Us offers a centralized, seamless experience that prioritizes the patient’s privacy first. When a Medi-Cal member gives consent to a provider to connect them to services through Unite Us, we ensure that their information will be protected and secure. That’s why we protect social care information under the same strict security standards required for protected health information under HIPAA and apply heightened protections for sensitive information such as 42 CFR Part 2-covered information.

Reimbursement for Social Care

Healthcare providers are reimbursed for the services they provide, and Unite Us believes that the same principle should apply to social care. With Unite Us Payments, funders can reimburse community-based organizations at scale, which can include Community Support and Enhanced Care Management Providers, for the services they already provide while measuring the success of social care funding initiatives over time.

Unite Us Payments simplifies the grant tracking, billing, enrollment, and authorization processes, aligning with CalAIM’s commitment to simplifying and scaling social care funding. This will centralize complex coding and rate information, boost efficiency, and scale impact while reducing risks of costly denials and rejections.

As an Enhanced Care Management and Community Support provider, we use Unite Us mainly for billing and so far, we have found the platform to be very user-friendly. We have also enjoyed the support from the Unite Us staff when dealing with minor issues and questions. The Unite Us Platform not only allows us to invoice for our clients but also to interact with other community support and thus extend the services we are able to provide for our clients.   – Merced County Rescue Mission

Enhancing Health Plan Outcomes

Hidden social needs can significantly impact the outcomes and experiences of health plan members. Aligning with CalAIM’s goal to improve quality outcomes and drive delivery system transformation, health plans can use Unite Us to:

• Better identify health-related social needs and risks in their population.
• Coordinate with responsive community partners for targeted interventions.
• Simplify reporting and demonstrate how they addressed diverse needs.

In the era of CalAIM, collaboration and innovation are key to achieving better health outcomes for California’s most vulnerable residents. Partnering with Unite Us empowers health plans to connect communities, streamline social care, measure impact, and simplify funding – ultimately improving the lives of the members they serve.

This is an opportunity to innovate, adapt, and grow with us!

Request a Demo

The post Enabling Health Plans To Meet CalAIM Requirements appeared first on uniteus.com.

In 2022, the United States was home to an estimated 16.2 million Veterans, all with different lived experiences during and after service, across branches, and over time. Therefore, it is essential that health concerns among Veterans and active service members are not considered monolithic. As such, the Veterans Health Administration (VHA) has adopted a whole health approach to care that supports Veterans’ health by empowering and equipping people to take charge of their health and well-being and to live their lives to the fullest. 

When addressing Veterans’ health-related needs, it’s crucial to recognize that health outcomes are influenced by more than just healthcare access. Veterans frequently encounter obstacles such as food insecurity, housing instability, transportation issues, and limited job opportunities. Addressing these needs will span various organizations, providers, and clinics, leading to an increased likelihood of care fragmentation, which risks information loss, medication issues, and gaps in service. Care coordination can help ensure that Veterans receive timely and high-quality care, avoid unnecessary duplication of services, and improve their overall health outcomes. According to a study by the Department of Veterans Affairs, Veterans who received care coordination had a lower risk of 30-day ED visits and a higher probability of PCP visits at 13–30 days post-ED visit compared to those who did not receive care coordination.

“Uniting health and human service systems through effective care coordination is the next step in reducing duplicity of efforts, maximizing return on investment for health care dollars for veterans and civilians alike, as well as improving outcomes for those who have served our nation.”  – Megan Andros and Reiley Burris from The Hill

Since its founding in 2013, Unite Us has launched a variety of networks to address the needs of Veterans and military families. As a Veteran-founded organization, Unite Us is uniquely positioned to assess and address social needs while assisting Veterans in gaining access to the services needed to retain health and thrive in their civilian lives. 

Our approach drives the collaboration needed for those serving Veterans and their families to:

• Identify and understand community needs to inform strategy.
• Deliver services by effectively engaging the right populations and collaborating with local partners to connect them to resources.
• Pay organizations for covered services.

Serving Those in North Carolina Who’ve Served

Since 2006, North Carolina—home to the eighth-largest Veteran population in the nation (621,000) and two major military bases: Fort Liberty (Army) and Camp Lejeune (Marine Corps)—has been focused on improving Veteran access to essential, coordinated services: benefits, health and wellness, employment, legal, and financial services. 

Since 2015, Unite Us has aided these efforts by building a statewide consortium of North Carolina-based Veteran service organizations through the NCServes network, now part of the NCCARE360 network which serves all community members. These organizations are vital in ensuring best-in-class service for Veterans and their families. Network partners include Veteran Services of the Carolinas, Veterans Bridge Home, the Governor’s Institute, and the NC Department of Health and Human Services (DHHS). To date, the network has served over 20,000 Veterans and active service members.

Over the last eight years in North Carolina, we have seen the unemployment rate of Veterans decrease from 3.2% in 2015 to 2.2% in 2022, and the rate of homelessness among Veterans decreased by 22% in the same time. While these yearly trends are reassuring, there is still a way to improve efficiency in care coordination: seasonal trend analysis. By utilizing real-time social care data and visualizing these needs over time, organizations can gain additional, actionable insight into the needs of the individuals they serve and improve outreach efforts.

Leveraging Real-Time Social Care Analytics

Of all North Carolinian active service members or Veterans assisted through the Unite Us Platform since 2018, the top overall needs were housing & shelter (50%), employment (26%), benefit navigation (20%), income support (18%), and food assistance (16%). 

Analyzing the needs of referred Veterans or active service members in the previous five years, we can begin to examine seasonal trends in need for those residing in North Carolina. Of the individuals sampled, the need for housing is persistent throughout the year, while the need for benefit navigation and employment assistance peaks at the start of the year. The need for financial assistance peaks during winter, and food assistance requests peak in summer and fall. (Source: Unite Us Platform data, pulled October 30, 2023)

With the most recent real-time data from 2023, we can observe how this year’s trends compare to the past. Proportionally, more Veterans and active service members require housing & shelter throughout 2023 than in the five years prior.

Using Unite Us, community-based organizations (CBOs) can observe real-time fluctuations in the needs of those they serve, improving planning and driving service allocation and targeted investment. 

Proactively Identifying Social Care Needs

Actively tracking service requests may only capture some of the community’s needs. For instance, due to environmental stressors specific to military personnel, there is an increased risk of substance use disorders (SUD); however, in our sample, this need remains proportionally scarce. To grasp the genuine need, we must consider all aspects of lived conditions and working environments to proactively identify social care needs, recognizing that the key to whole health lies in understanding the broader spectrum of services.

Unite Us Social Connector helps organizations proactively identify social needs in their communities through the Unite Us Social Needs System (SNS)—the industry standard for predicting and measuring individual-level SDoH in populations across the country. It empowers organizations to utilize data to inform care management, community outreach, funding strategies, and intervention design. This solution enables veteran-focused organizations to proactively understand the needs of Veteran households, connect them to needed services, and ensure appropriate programming exists for them throughout the state. 

Takeaways: Strategies for Addressing Veterans’ Health-Related Social Needs

Unite Us is proud to help serve those who have served our country in our nationwide networks. Through our dedicated efforts, we have identified key strategies to keep in mind when addressing the health-related social needs of Veterans: 

• Whole Person Approach: Veterans’ experiences and needs are diverse and unique, requiring a holistic, cross-sector approach beyond healthcare access.
• Importance of Care Coordination: Care coordination is vital to ensure timely and high-quality support, preventing duplication of services, and improving overall health outcomes for Veterans.
• Real-Time Social Care Analytics: Analyzing real-time data helps identify seasonal trends in Veterans’ needs, enabling care organizations to plan and respond effectively.
• Proactive Social Care Needs Identification: Understanding the comprehensive spectrum of Veterans’ needs is vital. Challenges arise in merely observing these needs through screening, emphasizing the importance of proactive identification to ensure a comprehensive approach to Veterans’ well-being.

Better understand the needs of Veterans in your community with Unite Us.

Learn more 

The post Serving Those Who’ve Served: Addressing the Social Needs of Veterans in North Carolina appeared first on uniteus.com.

We know that coordinated care teams can help improve community health outcomes by addressing health from every angle. Our technology facilitates the journey, starting from a client’s first interaction with a care provider. Onboarding organizations into our software is simple, but engaging those organizations to become active and collaborative partners is much more complicated. Building effective community partnerships requires a personal connection that takes time to build. While technology can help streamline the process of building patient-centered networks of care, a human touch is still essential.

Recently, Unite Us hosted a webinar, The Secret to Provider Engagement. This allowed a group of our network leaders to share their best practices, learn from other community experts, and inspire dialogue around the importance of engaging your community’s service providers. The conversation included over 35 of our network leaders, several of whom spoke up about their experiences working with their partners and clients daily.

As a Customer Success Account Manager, I work hand-in-hand with network leaders to build and maintain high-quality networks through active partner engagement. Here are five proven methods for building effective community partnerships.

1. Understand where a service provider lies on the engagement continuum before you interact with them.

You shouldn’t approach every community partner in the same way. It is crucial to know your audience and tailor your communications to fit their lens. As said by Nicole R. French, Psy.D., of Veterans Bridge Home, “It is important to understand what an organization’s mission is. What tools they use to support their mission; to understand their workflows.” When approaching service providers, there are always different variables at play, so remember to keep their context in mind. Knowing as much as you can about each partner will help you understand their pain points and the needs of their organization. This information prepares you to address them appropriately and deliver the value proposition. Service provider engagement depends on understanding the relationship between that partner, the network, and the community.

2. Be personal—in real life and online.

People appreciate authenticity. Use the right language! Say “we” or “us,” not “you” or “them.” Be conscious of your tone and word choice. This goes along with method number one; you’re going to want to know a little about each provider in order to form that genuine connection. Find out what each provider needs, and if you don’t know, ask. Ask open-ended questions. Get to know their stories. Don’t hold back from sending personalized emails. Whether it’s welcome emails, informational emails, invitations to community events, a simple message takes a few minutes to write but could mean the world to someone who feels disconnected.

3. Build trust by using all the tools available to you and solving people’s problems before they know they exist.

Leverage the tools at your disposal. All service providers in our networks are equipped with the software, the information, and perhaps most importantly, the data that they should need to show potential partners the network’s value. Aggregate, real-time data is tremendously powerful, so be prepared to use it. These numbers can help you address any objection a prospective partner may have and elicit the value collaboration brings to your organization. Always leave people with something to remember you by. A pamphlet, a flyer, or even a business card is a tangible reminder that can both educate your partners and remind them that you’re there. Share personal anecdotes to relate to your audience. If you continue to act as a reliable source of information, personalized support, and effective solutions, people will see the value in your network. Use your tools.

4. Set expectations early on to make communication smooth throughout the whole process.

Make your ask clear and follow through. When building a relationship with your community partners be sure to relay what you expect of them and what they can expect from you. During the Unite & Learn webinar, Brandon Wilson of the Asheville Buncombe Community Christian Ministry spoke about how he breaks providers into groups based on the number of referrals they send. This helps him easily survey providers to see where they stand. If they aren’t reaching benchmarks, he knows to reach out. Keeping an eye on partner progress will help to gauge network success. By establishing a common set of standards in the beginning and following through on these standards throughout, you ensure the foundation for lasting engagement.

5. Hang in there—building effective community partnerships takes time.

Formulate a plan and stick to it. Network building is a gradual process and there’s no good way to rush it. As put perfectly by Paul Berry, USO of North Carolina, “You have to be where they’re at. If I get five minutes with my provider it has to be the most impactful five minutes of my day.” Spend time with your partners. Offer to walk them through their onboarding and registration processes. Invite them to In-Progress Reviews, weekly calls, and in-person meetings. Assess their progress and share what you know. When it comes to keeping your partners engaged, consistency is key.

Each of these strategies can be used differently depending on your partners’ unique needs. At Unite Us, we strive to share the lessons we learn with each community we work in. We know that technology and effective community partnerships are decisive in building healthier communities. The tools we’ve built can help your community shape thriving, scalable, and sustainable networks of service providers working together to help every client that walks through their doors.

A special thanks to our partners at The Institute for Veterans and Military Families, NCServes, and all who have contributed to our work in building healthier communities together.

Interested in learning more about how to bring Unite Us to your organization?

Get in Touch

The post 5 Tips for Building Effective Community Partnerships appeared first on uniteus.com.

Across the country, communities are facing significant challenges in meeting the growing needs for behavioral health care services. Healthcare and community-based organizations alike have seen that they cannot tackle this surge in demand alone.

In this webinar, discover the strategic and coordinated efforts that champion a comprehensive and proactive approach to mental wellness—leaving no individual or community behind.

You’ll learn: 

• The pivotal role of community-based organizations in enhancing mental health care delivery
• The importance of building networks that embrace diversity and cultural sensitivity
• Strategies for seamless collaboration between healthcare organizations and local community partners

The post Improving Behavioral Health: A Community Effort Webinar appeared first on uniteus.com.

Person-Centered Maternal Care

The First 1,000 Days Suncoast initiative in Florida, led by Sarasota Memorial Health Care System, shows us a path toward proactive, person-centered maternal care. This pioneering, cross-sector collaboration is focused on supporting pregnant women, new parents, and their families by addressing their unmet social and healthcare needs.  

Together with Unite Us, Sarasota Memorial Health Care System conducted a study demonstrating that addressing unmet social needs may significantly improve maternal outcomes while reducing overall healthcare costs. Results included:

• A 79% reduction in the odds of postpartum-related readmissions for Medicaid enrollees 
• Over $350,000 estimated savings for all-cause readmissions per 1,000 deliveries
• Continued reduction in odds of hospital admission up to 12 months after delivery 

These key factors drove the study’s success:

• Streamlining collaboration with the community to deliver care outside the hospital’s four walls 
• Incorporating patients’ lived experiences in program and service design 
• Using technology to support cross-sector collaboration, securely collect actionable data, streamline care coordination, and measure the impact on people’s lives

The Launch

The Charles & Margery Barancik Foundation launched First 1,000 Days Suncoast in 2018 to improve care coordination and increase access to care for pregnant mothers and families with young children. Composed of more than 85 partner organizations, First 1,000 Days identifies the most pervasive barriers families face and develops innovative solutions to increase connections to help. The philanthropic dedication of numerous foundations and donors, including Sarasota Memorial Healthcare Foundation, support the operations and a dedicated team to lead the work.  

Following the Collective Impact Model, the initiative relies on Sarasota Memorial Health Care System as its backbone organization, which leads the strategy and operations. In 2020, First 1,000 Days turned to Unite Us to provide the technical infrastructure needed to support cross-sector collaboration. 

Screenings and Workflows

As the backbone agency, Sarasota Memorial has implemented various programs to better support families, including universal social drivers of health screenings and a Family Navigation service. 

Every time a maternity patient arrives in the hospital, a staff nurse talks with them about their social support needs. When they identify a need, the nurse notifies a case manager through the electronic health record system. Then the case manager visits the mother or parent to do a more thorough assessment of the whole family’s needs, including those of the parents, any caregivers, and other children in the household. After completing the assessment and gaining the individual’s consent, the case manager then securely sends referrals for needed social services through the Unite Us Platform. 

A First 1,000 Days Family Navigator responds to requests for help that come from mothers and families in the community through a public, Unite Us-powered assistance request form.

A New Maternal Health Ecosystem

In a survey on care experience, local care providers and families in Florida identified “difficulties navigating the healthcare system” as one of their top barriers to better maternal care. 

At a recent webinar, Meeting Mothers Where They Are: A Community and Person-Centered Approach to Care, leaders from Unite Us and Sarasota Memorial discussed both the program’s success and how it addressed challenges.

As Dr. Chelsea Arnold, the First 1,000 Days’ Manager at Sarasota Memorial, puts it, “With First 1,000 Days, we’ve moved from a maze of resources to a coordinated system of care that improves the health and well-being of mothers, families, and children.” 

“Gone are the days of people calling community agencies and hearing, ‘I’m sorry, we don’t know who can help.’ With Unite Us, we now have the resources, tools, and partnerships to connect the whole family to the right support.”

Results

Unite Us’ software allows program leaders to measure the impact of social needs interventions to improve maternal care quality. Presented by Unite Us Director of Research and Evaluation Dr. Amanda Terry and evaluation co-lead Dr. Arnold, the data illustrates that First 1,000 Days’ efforts have made significant improvements in maternal health outcomes at Sarasota Memorial. 

Specifically, when we compare patients receiving closed-loop referrals through Unite Us to matched patients receiving usual care (n=2,456), we saw statistically significant reductions in their odds of hospital readmission 30 days after delivery (p <.05). And the impact on health outcomes continues three, six, and twelve months after delivery. 

More details on this research and key metrics are available in this short case study. 

Key Takeaways

• The program made interventions easier and more effective. Sarasota Memorial case managers, nurses, and First 1,000 Days’ navigators can quickly and efficiently identify a family’s needs, take action to help them get the right support, and feel confident that any referrals or requests will be followed up. 
• Another powerful element of the program is its no-wrong-door approach. No matter where a family enters the system—whether through the hospital or one of First 1,000 Days’ partner organizations—they’ll quickly get the support they need. 
• The program leaders know how important it is to rely on parents’ lived experiences as experts in their own lives. As Dr. Terry stated, “Behind all the data and systems are real people with real stories, and those stories matter. Great care starts by listening closely to people with lived experiences, and incorporating their perspectives into programs designed to serve them.” 
• Blake Neathery, a one-time program participant who is now a community leader, says, “The best thing you can do is be authentic, honest, and supportive with families without judging them for what they’re going through. A lot of families are experiencing trauma and are really scared to share their challenges, and afraid of entering the system. What you say to them matters. Instead of asking ‘What’s wrong with you?’ we need to say, ‘What happened to you?’ and ‘What support do you need?’” 
• As mothers and families learn about the resources available to them, more are reaching out for help, knowing they will not be judged or rejected. This work is strengthening families and giving parents confidence in raising their children. 

A Scalable Solution

The success of First 1,000 Days Suncoast demonstrates the power of collaborative efforts that bring parents, community professionals, social services groups, and healthcare organizations together. The Unite Us Platform makes this impactful collaboration possible. 

With the insights Unite Us provides, our partners can identify changes in social services needs, understand inequities, and look at co-occurring needs to make sure they’re connected seamlessly. Working together with partner organizations will continue to expand programs and projects that improve maternal and family health.  

That’s a model that can be scaled and replicated in communities across America. Social services are extremely important for individual and community health, and their impact on health outcomes, costs, and quality of life is transformational. 

More Resources

• Watch the webinar on demand to hear from program leaders and learn from their experiences.
• Download this case study with more information on research and metrics.
• Read an interview with Dr. Chelsea Arnold.
• Get in touch with Unite Us to learn how you can apply these key findings to your needs and priorities.

The post How Social Care Improves Maternal Health Outcomes: Learn from Innovators at Sarasota Memorial Health Care System appeared first on uniteus.com.