Social care is a complex and rapidly changing landscape. Many people across the US have unmanaged medical conditions, face challenging social and personal barriers, and have fallen through the cracks despite the massive investments that healthcare organizations and government agencies have made in people, technology, and outreach. 

The Cost of Falling Through the Cracks

• + 59% total cost of care
• + 79% inpatient hospital admissions
• + 100% emergency department visits

Source: 2022 Impact Report

People with the most challenging social and healthcare needs usually reach out to the organizations and community groups they trust the most. Being able to request support in a secure, reliable, and efficient way makes sure those individuals can access the services and support they need, no matter which door they open.

The Power of an Assistance Request Form

That’s where Unite Us comes in. We partner with provider, health plan, government, and nonprofit organizations across the nation to launch Assistance Request Forms (ARF) that help individuals get connected to social care. 

How It Works

An Assistance Request Form is a public-facing form that enables people to quickly request the services they need, such as food support, housing, or employment assistance. In the form, they can securely share their own or a family member’s basic contact information in addition to the type of need, a short description of the need,  and their consent for this information to be shared with a secure network of providers who can help. The ARF is available in 35 languages to ensure that people can get connected to the care they need as seamlessly as possible.  

After the ARF is submitted, there are two options for what happens next: 

1. Direct response from community-based organizations (CBOs) – If CBOs on the Unite Us Platform have opted to directly respond to ARFs, then the submission will be sent to a recipient organization’s dashboard. At the receiving organization, the relevant users will be notified of the inbound requests for services, and they can reach out to the person directly to provide support.
2. Support from Unite Us Care Coordination Team – Another option that organizations can take is to loop in the Unite Us Care Coordination team. The Unite Us Care Coordination team serves as social care coordinators by identifying and executing appropriate client referrals, taking the onus off of in-house organization administrators. The Care Coordination team will reach out to the person who submitted the ARF form to gather more information as needed, and send a referral through the Unite Us Platform to a local organization that can help. 

Ultimately, in both scenarios, the person who submitted the ARF is seamlessly and securely connected to the care they need. 

Get Started 

Interested in learning more about how Assistance Request Forms can further your SDoH strategy? Request a demo to get started today. 

Request a demo

The post The Power of Assistance Request Forms in Connecting People to Social Care appeared first on uniteus.com.

With our proven track record of successfully facilitating secure closed-loop referrals and social care payments in New York and other Medicaid waiver states, Unite Us stands ready to support this important initiative.

Key Insights on Social Care Components

Social Care Networks (SCNs): 

SCNs, or contracted entities in each of the State’s nine regions, will be charged with establishing a network of social services and community providers to deliver eligible Medicaid beneficiaries with HRSN screenings and referral services. The State will reimburse selected HRSN services related to housing, food, and transportation.

Managed Care Plans: 

Managed care plans will contract with SCNs to deliver the selected HRSN services through two tiers of benefits. Level 1 services will be available to all Medicaid beneficiaries and will include referrals to existing public programs that are separate from the newly authorized HRSN services; Level 2 services will be provided to targeted beneficiaries who meet certain criteria. Subsequently, MCOs will be required to report data in order to evaluate the utilization and effectiveness of the HRSN services on health outcomes and equity of care.

Hospitals:  

Safety net hospitals located in Brooklyn, Bronx, Queens, and Westchester Counties can apply to participate in a Medicaid Hospital Global Budget Initiative that aims to help safety net hospitals transition to a global budget system. This initiative is designed to empower selected hospitals to prioritize population health and enhance quality of care in order to stabilize their financial situations and advance accountability and health equity.

Together, Driving Impact in New York

Building upon our ongoing collaborations with valued partners and community networks in New York, we are ready to deliver the solutions needed to successfully achieve the goals of the waiver while establishing a sustainable infrastructure for the continuous delivery of social care.

Leveraging Our Experience with State Medicaid Programs

We are proud to have established a reputation as the leading software solution for Medicaid programs addressing HRSNs across the country. Our cross-sector collaboration tools support a no-wrong-door system of social care, produce comprehensive insights to measure social need and community capacity at scale, and enable government leaders to strategically shift investments upstream to community-based partners, maximizing health benefits and better managing government spending. Like many Medicaid leaders, we know that social care coordination will improve outcomes, so we built our tools to collect structured social care data using a longitudinal care record. This allows states to measure real-time network performance and conduct integrated or longitudinal program evaluations over time, which will be critical in New York.

With networks in 44 states and partners leading the way in Medicaid transformation across the country, we’ve learned a lot about how we can support this critical work. Here are just a few examples:

We’re proud to support partners across the country in leveraging our solutions to support Medicaid waiver initiatives and advancing whole-person care. Interested in learning more about Unite Us solutions?

Get in Touch

The post Unite Us Celebrates the Approval of the New York State 1115 Medicaid Waiver: Improving Access to Care and Advancing Health Equity Together appeared first on uniteus.com.

County governments are on the frontlines of many of our nation’s most pressing challenges. From natural disasters and economic hardship to the opioid crisis and lingering public health issues stemming from the COVID-19 pandemic, county leaders and workers are managing one crisis after another—and often, managing multiple crises at the same time. In addition to being responsive to these emergent needs, many of America’s 3,000+ counties are responsible for providing their residents with critical services like public safety and child protection. In part because of their sheer volume of responsibilities, counties are leading the way in creating innovative solutions through collaborative partnerships. 

Join Unite Us as we hear from local leaders across the country who have unleashed innovation in government by leveraging technology solutions and community partnerships to address constituents’ health-related social needs and improve service delivery.

In this webinar, we’ll dive into: 

• Success Stories: Discover how county leaders are leveraging technology to improve government services and the health outcomes of their residents.
• The Power of Collaboration: Learn about the partnerships and networks that are driving collective impact beyond county borders.
• Expert Insights: Gain valuable insights and lessons learned from experienced leaders. 

Whether you’re a government official, community leader, or are simply interested in the evolution of public service, you won’t want to miss this important discussion.

The post Local Leaders: Unleashing Innovation in Government appeared first on uniteus.com.

Our Power in Partnership series highlights our national and regional partners and the work they do to build healthier communities.

Tell us more about your organization.

The Rhode Island Office of Veterans Services (RIVETS) acts as the chief advocate in the State of Rhode Island for Veterans and military families. RIVETS works day in and day out to ensure Veterans are receiving the full measure of all benefits for which they are eligible – benefits that they’ve earned and deserve. We offer programs and services at three key locations: the Veteran Resource Center in Warwick, the Veterans Home in Bristol, and the Veterans Memorial Cemetery in Exeter.

What are the greatest needs of the individuals and families you serve?

As with many human service providers, families often come to us during challenging times in their lives. With that said, the greatest demand we see at our Veteran Resource Center is assistance with benefits navigation, followed closely by transportation.

What are the main programs or offerings that your organization provides?

While the Veterans Home and the Cemetery are large operations under our oversight, the Veterans Resource Center and the services we deliver there have really grown over the last few years. We have two VA-accredited Veterans Service Officers on staff providing individual in-person counseling and support to Veterans, active duty, guard, reserve, and military families. Just over the last few years, we saw the number of unique individuals served go from 294 in 2021 to 894 in 2022. From January 1 through September 30, 2023, we’ve assisted 1,593 unique clients.

How has working with Unite Us impacted the work that you do?

The insights the Unite Us system provides, including data tracking and analysis, have allowed us to implement new programs and services that are responsive to the needs of the Veterans and families we serve. The data was telling us that transportation was a huge unmet need. Many injured, ill, and disabled Veterans were identifying access to reliable transportation, including services to get them to and from VA health care appointments, as critical and important to reintegration efforts. In response to this, RIVETS launched our VetPass program to assist eligible Veterans.

“Unite Us has allowed us to serve more and more Veterans and military families due to the power of the network and the data we are able to extract from the system. Data helps to drive our priorities – the services and investments needed to care for Rhode Island’s Veterans and their families. Unite Us is a powerful tool that ensures every Veteran receives the services they’ve earned and deserve.” – Kasim Yarn, Director of Veterans Affairs for the State of Rhode Island

How does collaborating with other community-based organizations play a role in your work?

Our mantra is that we are committed to meeting Veterans and their families where they live, work, learn, age, and play. We continue to expand our network of partners and increase our engagement in the community – we’re at community resource fairs, partnering with the United Way 2-1-1 bus, attending pre-deployment events and transition assistance programs. Collaboration with community-based organizations is essential to our success and the Unite Us Platform has enabled us to do this work much more efficiently and effectively. We could not support our Veterans without the support we receive from our municipal, state, federal and community partners.

What’s next for RIVETS and Unite Us?

We look forward to adding more Veteran-serving organizations to the network and closely partner with Unite Us when onboarding a new organization. We know that speedy, accurate, and secure sharing of information only helps us to get Veterans the assistance they need – and that they deserve for defending our freedoms. We look forward to continued partnership resulting in constantly improving services for our nation’s heroes.

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

Get in Touch

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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.

Building Successful County Partnerships

Here at Unite Us, we’re proud to partner with counties doing incredible work for their constituents across the country. With rapidly growing partnerships in 44 states, we’ve driven change in all types of communities, from the smallest towns to the largest cities. Our policy team members, made up of former government employees with decades of experience in public service, serve as thought partners to county leaders looking for new, effective ways to get things done. Our cross-sector collaboration tools empower counties to leverage their full resources, understand community-level data, and transparently manage their funding. Our local, community engagement team members can amplify the work of public-sector and nonprofit employees. In the 10 years since Unite Us was founded, we’ve learned a lot about how county governments can best prepare county partnerships and programs for success. From community collaboration mechanisms to using data to measure success, here are our lessons learned on how Unite Us can best support county governments looking to get things done.  

1. Leveraging Community Partners to Ensure Collaboration

Local governments are home to incredible community-based organizations (CBOs) that support their constituents on a daily basis. From food pantries and transportation providers to housing shelters and workforce training programs, CBOs are trusted sources of support in the community. Too often, CBOs are underfunded and forced to operate in silos. As a result, the services they provide are fragmented and may fail to meet whole-person needs. Government can be the convenor, but often needs support with execution. That’s where we come in: Unite Us’ software bridges gaps by allowing CBOs, health systems, and governments to securely communicate and coordinate with each other to achieve shared goals. 

Community transformation is possible, but only when all parties are singing from the same sheet of music. While this is true for any type of health or social care transformation, it’s especially relevant for counties looking to shift toward a more holistic way to address residents’ needs. In those cases, it’s critical that local governments play a leading role in connecting health systems with social services providers to quickly and efficiently deliver services to constituents in need. 

2. Managing Federal, State, and Private Funding to Ease Administrative Burden

Local governments often manage complex, braided funding streams. From federal and state grants to philanthropy dollars to opioid abatement funds, managing the specific reporting and billing constraints that come along with these funds can place additional burdens on already overworked staff. Unite Us provides the technological infrastructure to manage different funding streams to ease the administrative burden and maximize impact. We facilitate social care funding through our platform by providing data and up-to-date reporting on where the funding is going and how it is being used. 

3. Driving Community Engagement Toward Better Health Outcomes

No matter the ZIP code, we know that providing children and families with the resources they need to succeed is critical to the overall health and well-being of any community. What sets Unite Us apart is that our team members aren’t just assigned to support counties from a remote office building somewhere—they live in the communities they serve and are deeply engaged in community work. 

When a local government joins a network of coordinated care, constituents of all backgrounds benefit from this local perspective. As a true partner to this work, Unite Us can help you: 

• Facilitate connections to a variety of healthcare and care coordination programs, including mobile clinics and health education programs. 
• Address rural transportation issues by establishing partnerships with transportation services such as taxi or bus services.
• Leverage paramedics and other community health workers to provide preventive services for those at risk of poorer health outcomes. 

4. Providing Data and Measurement Tools to Track the Success of Public-Private Partnerships

No partnership can be effective unless all parties involved agree on common goals and have access to the same data and measurement tools used to track progress. Often, government agencies track data differently than the CBOs they work with, or even other agencies in their state or county. As a result, it can be incredibly challenging—if not impossible—to measure the effectiveness of any intervention or program. 

When counties join a Unite Us network, they gain access to a data collection and tracking system that is responsive to their specific progress needs and allows all partners to evaluate outcomes the same way. Shared measurement and data is the key that gives leaders the information they need to tailor programs to maximize efficiency and amplify their impact. 

5. Enabling Whole-Person Service Delivery

Counties have the agility and flexibility to drive innovative solutions that are harder to achieve at state or federal levels. Increasingly, counties are adopting a whole-person model of health care that prioritizes social drivers of health (SDoH) just as much as the physical symptoms people experience. By connecting healthcare providers with government agencies and CBOs, Unite Us breaks down silos that threaten to derail whole-person care. And with our closed-loop referral system, leaders can have confidence that a patient’s SDoH needs are actually being addressed and treated. 

No matter what challenges you want to address in your county, Unite Us is ready to provide the technology and expertise to make it happen. Reach out to us today to learn more. 

Get in Touch

The post County Partnerships: Lessons Learned from Ten Years Working with County Governments appeared first on uniteus.com.

Addressing social needs is now at the forefront of policy and industry innovations to deliver whole-person, high-quality care.

This webinar explores new incentives and requirements for healthcare organizations to integrate social needs screenings and interventions in their care model. Plus, discover lessons learned from pioneering efforts that have advanced our understanding of how to address social needs to improve health outcomes.

The post How Addressing Social Needs Will Transform Healthcare Webinar appeared first on uniteus.com.

Our Power in Partnership series highlights our national and regional partners and the work they do to build healthier communities.

Tell us more about your organization.

San Joaquin County Public Health Services (PHS) is the local health jurisdiction for San Joaquin County. Through various health programs, our goal is to protect, promote, and improve health and the conditions that impact well-being for San Joaquin County residents.

What are the greatest needs of the individuals and families you serve?

Since we started using Unite Us, we have served over 300 constituents and have made over 620 referrals through our program. The greatest needs of the people we serve include benefits navigation, food assistance, housing and shelter, and individual and family support. Through our partnership with Unite Us, we are able to easily find these critical resources for clients and ensure their needs are met. 

What are the main programs or offerings that your organization provides?

In addition to our ongoing health offerings that primarily focus on encouraging healthy lifestyles and disease prevention, one of our newer initiatives is a Community Health Worker (CHW) program designed to address high risk residents’ vaccine and testing hesitancy, improve access to preventive health care services, increase management of underlying health conditions, and improve social determinants that serve as life barriers to care. To kick off this effort, PHS received a large grant from the CDC in 2021 to fund CHWs throughout the county. So far, 35 CHWs across 13 health and community-based organizations have been trained on the core competencies of this work. Another 35 will be trained in the third year of our program, as we continue to build our CHW network.

We have also worked closely with the Unite Us technical assistance team to train program staff. Many of the organizations in this program already utilize and are familiar with Unite Us. In addition, we have onboarded and trained six community and faith-based organizations to the network and continue to use the Unite Us dashboard daily to securely send and receive referrals. 

How has working with Unite Us impacted the work that you do?

Unite Us has become a one-stop shop for PHS and our sub-contracting organizations, as well as many other organizations in San Joaquin County. PHS is one of the first local health jurisdictions in California to become part of the Unite Us network. Because the platform is so user-friendly, our CHWs are able to send and receive referrals connecting clients to services in a timely manner. Thanks to Unite Us’ closed loop referral capability, we are able to track client progress and, ultimately, drive toward better population outcomes. 

“Unite Us provides client-centered care coordination and a quicker and more efficient connection to the services clients need. Their client-centered approach gives a sense of importance to the clients because organizations/agencies are reaching out to them, instead of them reaching or calling the organizations for their needs.” – Maria Argayosa, Community Health Worker at San Joaquin County Public Health Services

The Unite Us staff who we have worked with have been amazing. They are very attentive, responsive, and easy to work with. 

Our program CHWs continue to go above and beyond for their clients, ensuring their needs are being met. The best thing about Unite Us is that it makes it so much easier for our community health workers to do what they do best. 

How does collaborating with other community-based organizations play a role in your work?

Community and faith-based organizations play a huge role in the work PHS does. Over 80 organizations are using Unite Us in San Joaquin County. Each of our partners plays an essential role in connecting our most vulnerable community members to free services and resources via the platform. They are continually helping us reduce social and health disparities and address social determinants of health to improve our community members’ overall well-being. 

What’s next for PHS and Unite Us?

We are excited to continue onboarding the many different PHS programs and services onto Unite Us. As of right now, we have worked to onboard five different departments within PHS but will continue to add more in the near future. This will ultimately help raise awareness of PHS resources and connect residents to services.

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

Get in Touch

The post Power in Partnership: San Joaquin County Public Health Services appeared first on uniteus.com.