How community-based organizations are taking a tech-driven approach to connect health services to social care

At a time when New York City has declared a state of emergency amid an influx of thousands of migrants, social safety nets have been strained. Inflation has led to a spike in demand for social services. Yet Mayor Eric Adams recently announced that the city may cut back on public services to focus on migrant assistance. 

The city’s largest public health nonprofit, Public Health Solutions (PHS), must operate despite these challenges with a network of hundreds of community-based partners that collectively serve more than 1,100 New Yorkers a month. To do so, a high level of connectivity is required to understand eligibility and process referrals. 

One health tech company has been facilitating those connections. True to its name, Unite Us offers a platform that connects health services to social care. The software aims to address social determinants of health and is free to community-based organizations like PHS. 

Unite Us bills itself as software to address social determinants of health, providing a platform that connects health services and social care. 

“Social determinants are the root cause of a lot of different issues across a lot of different systems,” Melissa Sherry, vice president of social care integration at Unite Us, told Fierce Healthcare. 

Along with community-based organizations, Unite Us also works with states, payers and providers. Network members can use the platform to send or accept electronic referrals to enroll people in services. Unite Us, which operates in 44 states, can also screen for social needs, predict the social needs of a population and collect outcomes data that can help drive meaningful community investments. 

“Everybody on all ends of the equation knows what’s happening to an individual so they don’t get lost in the system,” Sherry said. 

A care manager or provider can use the platform to browse services available and filter by need. They will be able to know whether an organization has space to take a patient if making a referral and if that patient went to their appointment. 

“That visibility is a game changer," Paula Masters, vice president of health programs at Ballad Health, told Fierce Healthcare. "That changes the way that we take care of our clients." 

Ballad Health, an integrated community health improvement organization serving the Appalachian highlands, launched Unite Tennessee last year with users from Ballad Health and more than 50 community-based organizations. In just over a year, powered by Unite Us, Ballad sent more than 1,110 referrals and connected more than 600 community members to care.

Before companies like Unite Us, which is Epic-integrated, providers and community organizations usually relied on a manual phone referral system, leaving room for a patient to get lost in translation, according to Sherry. 

“It wasn’t systemic, and the data wasn’t collected in a way that you could understand the whole picture,” Sherry said. 

Indeed, Ballad Health had "no pathway" in place for nonclinical referrals prior to teaming up with Unite Us, Masters said. Between phone calls, faxes and emails, the work was all manual. The organization began to develop its own directory of resources, "but we couldn't do it in a true system fashion until Unite Us." 

By the end of 2023, Ballad Health plans to complete its Unite Us rollout, with a universal social screener and partner directory for matching patients to services in the EHR system. Having the technology to serve a rural area "makes that equity goal much easier to obtain," Masters said.

Today, Unite Us works with thousands of community-based organizations. Community engagement managers help ensure network members know how to use the technology. If one is struggling to respond, they offer additional training. If an organization has a capacity problem, they can elect to temporarily stop receiving referrals while Unite Us helps them figure out additional funding options.

Network members can still make referrals to outside organizations—the experience is just less cohesive and more effort, Sherry noted. 

Last year, Unite Us acquired Carrot Health, a consumer data company that leverages predictive analytics to help payers and providers understand their populations’ needs. Referring providers can see the top needs and demographics of a population, the success rate of referrals and how quickly patients are accepted. The data are deidentified, but payers can ask individuals to share more data. 

The company last year also scooped up another major player in the market, NowPow, to scale its integrated health and social care networks.

Social determinants have received a renewed spotlight within the industry as the COVID-19 pandemic exacerbated existing health inequities. This has led to social determinants investments as organization take a tech-driven approach to connect patients with the social services they need.

Startups focused on the social determinants of health are also attracting big investment dollars as well as spurring M&A deals. Health technology company WellSky acquired Healthify to scale up its social determinants of health initiatives.

Other startups in the space include findhelp, formerly Aunt Bertha, as a referral service to help connect people to social services. There are also companies in the social determinants analytics camp such as Socially Determined, Arcadia, Signify Health and Health Catalyst. Socially Determined clinched $26 million in a series B funding round back in June to scale up product enhancements, sales and marketing efforts and R&D on tech. 

Sherry argues Unite Us tech would be especially useful for accountable care organizations (ACOs) and value-based clinics because of the data it provides and its ability to tie to payments in a performance-based way. In March 2022, Unite Us launched Social Care Payments, a solution meant to bridge the gap between healthcare funders and community organizations. It allows all stakeholders to access and pay for social care through an integrated process and tech platform.

Between screenings, referrals, accepting a patient and enrolling them in a service, “that makes for a nice cascade of payment points that can be shared across partners,” Zachariah Hennessey, executive vice president and chief strategy officer at PHS, told Fierce Healthcare. That way, providers and social service organizations can share accountability for a patient.

For years, PHS coordinated clinical services without technology. 

“The social service landscape is even more fragmented, disconnected and siloed than the healthcare landscape,” Hennessey said. 

In 2018, PHS decided it needed something for its diverse group of community health workers that “was easy to take up, facilitated communication among them and made their jobs actually easier and more efficient,” Hennessey said. 

Prior to implementing the platform, a fifth of participants screened in PHS' nutrition program were enrolled in one or more social services. After rolling out Unite Us, the number of participants enrolled rose to 60%. What was key to that success was not only introducing the technology that streamlined the referral process, but also the funding, training, technical assistance and collaborative design Unite Us offered, Hennessey said. 

Being able to track population health data also proved invaluable. During its nutrition program, in collaboration with NYC Health + Hospitals, PHS was able to see who was receiving resources or not, and why. That helped identify gaps in care and services “at a scale that you can lift up for the purposes of securing more funding,” Hennessey said.