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The Healthcare Provider’s Guide to Building an Effective Social Health Strategy


In January 2021, the Biden Administration issued an Executive Order on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.” In response, the Centers for Medicare and Medicaid Services (CMS) launched a strategy to improve health for all by addressing “inequities in health outcomes, barriers to coverage, and access to care.”  

To that end, CMS is seeking to focus providers on connecting health outcomes to broader community care needs through a variety of programs. These range from the recently announced “Birthing-Friendly” hospital designation aimed at improving maternal health to data collection rules that will require providers to assess health-related social needs and deliver more equitable care that improves health outcomes.  

While these requirements are not yet mandatory, what can providers do now to build an effective social health strategy and prepare for that future reality? 

Health for all is healthcare’s next great challenge. An effective social health strategy is critical for providers to meet the non-clinical health needs of their patients and local communities. 

Grasping the Tip of the Iceberg

Eighty to 90 percent of health outcomes are due to behavioral, social, or environmental factors that go beyond clinical care, including socio-economic status, race, nutrition, housing security, transportation, and more. For this reason, health inequity has a powerful influence on factors that influence health. The consulting firm Deloitte estimates that health inequities cost the U.S. $320 billion per year and could rise to $1 trillion by 2040 if unaddressed. At an individual, family, or community level, the toll on health, quality of life, and well-being is just as profound. 

When physicians, nurses, public health officials, and others in the healthcare field encounter a patient or member who faces challenging environmental circumstances, they know it’s very likely the care they provide will not be enough to meet that person’s overall needs. After the appointment or care encounter, the patient may return to the same environment that caused or exacerbated their health problems in the first place, and that environment can present barriers in their adherence and recovery. 

Physicians everywhere have encountered this challenge across broad populations of patients throughout the COVID-19 pandemic. Across the nation, physicians observed the communities hit hardest by the pandemic firsthand: rural communities, Black and Brown communities, and marginalized groups with historically limited access to care. These populations faced extensive social care needs that rendered medical treatment a temporary bandage for other challenges.

Consider this example: A patient who is unable to manage his diabetes becomes a frequent visitor of the emergency department. Concerned, the physician takes matters into his own hands and applies for a grant that enables him to assign a community health worker to the patient’s case. The health worker discovers the patient is experiencing homelessness and has no place to store his insulin. The community health worker can then connect the patient to a local shelter, where he is able to stay and store his insulin. 

Identifying that patient and connecting him to the right social resources helped improve his health outcomes and reduce the burden on the local hospital. The bigger challenge, however, is achieving that kind of impact systematically and at scale.

Connecting Health to Social Care

To tackle this challenge strategically, a provider needs an innovative analytics approach that defines and measures social and economic risk and a tight network of community-based organizations that can help meet social care needs. Few provider organizations can meet this challenge on their own. 

CMS’ health equity data requirements will motivate provider organizations to collect social risk measures the way they have long collected clinical risk measures, like elevated blood pressure readings. CMS-approved drivers of health (DOH) screening measures will help, but it can be very difficult to get a comprehensive understanding of a patient’s whole-person needs. At the same time, neighborhood- or community-level risk scores don’t always tell the whole story. For example, research published in JAMA Network Open found that 42 percent of patients with at least one social risk lived in neighborhoods not defined as underserved. 

Unite Us has developed a comprehensive Social Needs System to enable organizations to evaluate individuals, communities, and regions across six key categories of need, creating a more personalized and precise approach.

What can the provider organization do once a social care need is identified? Given that needs and circumstances can vary widely, it can be difficult to find the right resources or services to help the patient. Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. This enables network partners to work together and meet complex individual, family, and community needs.  

Just as importantly, the Unite Us Platform allows partners to securely track a patient’s progress through a referral to confirm they’re receiving the right care down the line and measure the resulting health outcomes. 

Closing the Loop

This closed-loop referral capability ensures that services meet patients’ needs and actually move the needle on health outcomes. This will be a critical skill when CMS makes it mandatory for providers to assess and address whole-person needs while also improving physical health. As commercial health plans engage more in value-based care, they will also require that provider organizations have the capabilities and resources to handle this complex set of challenges. 

It’s time for provider organizations to prepare for that future. With the right technology and network, they have the opportunity to position themselves for success in a world where health for all is fundamental. Physicians, nurses, and public health workers will have the resources to ensure that their patients are connected to the right organizations that can meet their deeper needs.

Clinicians and public health practitioners want to improve their patients’ whole-person care. Government, local communities, and healthcare providers want to address all care needs at scale. By working together through collaborative technology, we can achieve these goals and unlock potential in every community. Everyone wins when we have a healthier population and access to health for all.

Learn more about how Unite Us can help healthcare providers improve health outcomes with whole-person care.

Our Solutions


About Unite Us

Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. Through Unite Us’ national network and software, community-based organizations, government agencies, and healthcare organizations are all connected to better collaborate to meet the needs of the individuals in their communities.

Topics: Health for All