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Medicaid’s Next Generation SDoH Strategy


Building Shared SDoH Infrastructure to Deliver Whole Person Care

Medicaid leaders across the country are aligning around a common vision of a more person-centered Medicaid program that addresses social drivers of health (SDoH), improves coordination of care, and invests in health-related social needs (HRSN). To make this vision a reality, states need new tools and technology to facilitate collaboration, to measure person-level outcomes and system impact, and to drive accountability across sectors and providers. Addressing HRSN and the broader SDoH also requires deep community engagement and cross-sector partnerships of the providers and community-based organizations (CBOs) that are committed to delivering whole-person care. 

 At Unite Us, we combine technology infrastructure with supported community infrastructure to break down silos across sectors and government programs. Through Unite Us’ interoperable referral platform—which uses an electronic master person index to empower cross-sector care teams and evaluate individuals’ longitudinal community care journeys—we create seamless system linkages and closed-loop workflows across historically fragmented systems of care. The common platform we provide supports a true “any door” system of social care, produces system-wide analytics to measure social needs and community capacity at scale, and helps government leaders strategically shift investments upstream to maximize health benefits and better manage government spending. 

Addressing social needs through the PHE unwinding

Unite Us can help make the Medicaid redetermination process more targeted and effective for members at high risk of social vulnerability and lost coverage. Using extensive health and social care data sets and direct outreach capabilities, Unite Us supports state efforts to deliver appropriate coverage and social support through our accountable social care networks. Specifically, we provide:

  • Social risk stratification to target outreach at the individual level
  • Updated member contact information and communication preferences
  • High-touch support for the most at-risk populations
  • Ongoing monitoring and evaluation of health and social risk

Addressing HRSNs and SDoH through Medicaid Managed Care

Medicaid programs across the country are updating quality measures, establishing new care management requirements, and testing innovative risk modeling to encourage a greater focus on SDoH amongst managed care plans. Shared end-to-end SDoH technology infrastructure can break down access and quality gaps between coverage options. It also standardizes approaches to program oversight by using common measurement, data, and systems to identify members’ needs, facilitate effective outreach, engage members in services, track member- and system-level outcomes, and facilitate investments in needed community-based services. 

Nationwide, Unite Us’ end-to-end SDoH data and technology suite provides a blueprint for plans and Medicaid programs to proactively leverage SDoH data and infrastructure to drive measurable health outcomes and return on investment. 

States Taking The Lead

1. Quality Measures:

Through their recently approved 1115 waiver demonstration, Oregon Healthcare Authority (OHA) redesigned its quality incentive program to include a new health equity upstream metric, “Social Determinants of Health: Social Needs Screening and Referral,” which incentivizes managed care plans not only to measure but also address HRSNs. The evolution of quality improvement measures related to SDoH is also being driven by leading healthcare quality standard entities, such as the National Committee for Quality Assurance (NCQA). The Social Need Screening and Intervention (SNS-E) measures are included in NCQA’s 2023 updated Healthcare Effectiveness Data and Information Set (HEDIS) quality measure slate. With this newly established measure, health plans can be evaluated on their ability to screen and provide interventions for members with housing, food insecurity, and transportation needs.

2. Care Management Programs:

In Mississippi, managed care plans will be required to implement comprehensive care management programs inclusive of SDoH screening, risk stratification, and trackable closed-loop referrals. These requirements underpin a program-wide commitment to advancing health equity that is financially incentivized through minimum investment requirements in SDoH, as well as Medical Loss Ratio (MLR) allowances for costs associated with closed-loop referral platforms.

3. Risk Modeling:

Incorporating social needs data into quality and risk adjustment programs is another important trend that ensures adequate funding is allocated to manage members’ social care needs. MassHealth, the Massachusetts state Medicaid agency, developed its medical risk adjustment model for managed care organizations (MCOs) and accountable care organizations (ACOs) by incorporating data found to be associated with heightened SDoH needs. The updated model considers age, unstable housing, a “neighborhood stress” score, disability, serious mental illness, and substance use disorders.

Unite Us predictive Insights solutions take a human-centered approach that leverages comprehensive and integrated health and social care data to systematically predict and measure social, environmental, and economic marginalization.Unite Us Social Connector provides community-level insights to help organizations be proactive in their SDoH strategies. With Social Connector, Medicaid programs can better understand the key social care needs impacting members at a community level. 

Social Connector+ provides person-level and community-level insights. Social Connector+ can provide Social Needs System (SNS) scores to support member-specific matching, outreach, and engagement to better understand the needs of members and the communities where they reside.

Our analytics framework sheds light on what social drivers are prevalent in each community and how they impact health outcomes. Unite Us’ SNS — the industry leading framework for SDoH analytics — systematically predicts and measures social, environmental, and economic disparities. We provide clear dashboards and access to meaningful and actionable SDoH data to enable organizations to:

  • Understand and address social vulnerability in a specific community
  • Monitor in real-time, and optimize decisions on, programs and resources 
  • Measure and report on impact

With actionable data in hand, and an extensive network of actively engaged CBOs, Medicaid programs can accelerate progress on priority initiatives (e.g., maternal health, transition supports for justice-involved, or housing insecure populations).

Shifting Investments Upstream

Through Medicaid waivers and other reinvestment initiatives, state Medicaid programs are advancing new initiatives to address HRSNs by directly funding CBOs that traditionally have not been financed by healthcare. The implementation challenge that states now face is how to create streamlined billing and reporting infrastructure for social care providers without over-medicalizing the delivery of needed community-level services. 

Implementation efforts for these initiatives must include a plan for supporting and reimbursing CBOs that provide health-related social services to create adequate capacity. In many instances, CBOs’ existing systems and workflows do not generate service-level invoices, manage reimbursements, or track outcomes. This is particularly true for smaller CBOs, which are often best positioned to serve vulnerable populations. These smaller CBOs and the populations they serve are likely to be left behind if states and health plans don’t provide them with the tools and support they need to participate. As Medicaid programs increasingly adopt requirements for connecting members to community partners, they must also invest in the protocols and technology needed to strengthen CBO capacity, including those needed for rate setting, reimbursement, and reporting.

With Unite Us Payments, CBOs can streamline service tracking and billing for social care services provided. Medicaid agencies using Unite Us Payments can track the flow of CBO funding and pair reimbursement with outcomes data to better understand impact and return on investment. Unite Us also generates data and insights, like our Health Equity dashboard, to provide our partners with actionable information that they can use to target resources and interventions to address local priorities, such as health disparities and inequities in access to care. 

Opportunities for Cross-Sector, Interagency Partnerships

As state Medicaid programs take the lead in promoting statewide coordinated care networks, local government and other agencies need coordinated care networks to address priority populations and advance specific policy objectives. In a mature network, Medicaid programs improve coordination across agencies to support multi-system members, including foster children, justice-involved individuals, people with substance use disorders, or children with special health care needs. Establishing reusable statewide SDoH infrastructure to advance community-level care coordination is core to Medicaid’s role as a safety net coverage option. Statewide plans to invest in SDoH technology as part of a state’s Medicaid Enterprise Systems strategy can include more than just the healthcare delivery system by engaging a cross-agency governance team to proactively set system-wide priorities and needs across multiple at-risk populations. 

Unite Us is the only SDoH technology vendor that has scaled statewide with government partners. We leverage a robust, cross-sector planning and community engagement methodology to ensure that government partners maximize state and federal investments through regular access to, and use of, key SDoH indicators collected through our robust structured outcome taxonomy and standard data visualizations. 

How Medicaid Scales Impact Across Systems of Care

In North Carolina, the Department of Health and Human Services has implemented the Healthy Opportunities Pilot (HOP), a first-in-the-nation effort to fund social care through Medicaid. In the first few months since HOP launched in March 2022, CBOs have provided nearly 10,000 social care services that are—for the first time—eligible for Medicaid reimbursement. In that same time, North Carolinians have received more than 5,000 food boxes.

97% of individuals identified by a care manager as eligible for the pilot were successfully enrolled in the program. After a service is approved through the CMS-mandated workflow, providers accept the referral to provide services within one day on average. And the rejection rate for claims is less than 3%, compared to typical clinical rejection rates of 10-20%.

Unite Us was selected by North Carolina to provide the technology infrastructure for HOP because of its prior work integrating health and social care providers across the state. In 2018, Unite Us built the first statewide network (NCCARE360) in the country that unites public and private health care and human services organizations with common technology infrastructure to enable a coordinated, community-oriented, person-centered approach for delivering care. Partner state agencies, such as the Department of Public Safety, also participate in NCCARE360 to provide closed-loop referrals for justice-involved individuals returning to their communities. NCCARE360 enables care delivery with high-touch, coordinated health and social care services as covered by the North Carolina Institute of Medicine; the Center for American Progress; Princeton School of Public and International Affairs; and  Politico.


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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.