This week’s approval of the New York State 1115 Medicaid Waiver is a major step forward in advancing a stronger, healthier state for all New Yorkers. At Unite Us, we strongly support the waiver’s ambitious goals of building a resilient, flexible, and integrated delivery system that will improve access to health and social care, advance health equity, reduce disparities, and support health-related social needs (HRSNs).
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.
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.
Accessing community resources like food, benefits, housing, and legal support can be incredibly difficult. It is a rare occurrence to be connected to the right resource at the right time. But thanks to our partnership with Unite Us, Public Health Solutions has developed a coordinated, accountable, and modern network of organizations, WholeYouNYC, that supports over 1,000 New Yorkers each month to access services in their community. Unite Us enables us to collaborate in real-time, deliver reliably and responsively, and provides the visibility we need to ensure no one slips through the cracks. We hope that the coming investment through New York’s Medicaid Waiver program supports us to bring this infrastructure to scale.
Since New York’s previous 1115 Waiver, HWCLI has led the Health Equity Alliance of Long Island (HEALI), Long Island’s Social Care Network, to build a comprehensive and integrated social care system for the region. In preparation for the upcoming waiver, our coalition partners have utilized Unite Us as a critical referral and communication tool to connect social care services across Long Island. Unite Us has been a responsive and collaborative partner by providing a technology solution to build the social care infrastructure necessary for our vision for Long Island
Our vision is to create a connected ecosystem of care across healthcare, government, and social care in the Hudson Valley to improve access to needed services for individuals and their families. Unite Us enables organizations in our region to better coordinate and collaborate in order to care for the whole person, through visibility into the status of referrals and ultimately what services are delivered. We look forward to scaling our work together under the New York 1115 Waiver to promote health equity in our region and beyond.
Northwell is proud to partner with Unite Us as we continue to expand our screenings for the social determinants of health to over one million. Unite Us is a thought leader that is fostering dialogue around best practices throughout our region and nationally. The upcoming 1115 Medicaid Waiver will help accelerate the work we are doing and forge new community partnerships that are committed to making a difference
The partnership with Unite Us has allowed the 360 Collaborative to begin preparation for social care payments, which is a critical component of the upcoming NYHER waiver. We have initiated a pilot that addresses food insecurity for individuals who have a Type II diagnosis. It has allowed us to have a better understanding of the resources dedicated for waiver implementation and partners are providing feedback in real-time on the support they need to make this social care delivery a success.
As organizations across New York move to implement the new 1115 Waiver, there will be an even greater need for effective and efficient integration of clinical and social supports. Through our collaboration with Unite Us, we have developed readily adaptable systems and processes to screen patients for social needs, initiate referrals, and connect with new and existing community partners. During and post-DSRIP, CCB has advanced programs and partnerships that improve quality of care and address social factors impacting the health of 1.2 million Medicaid recipients in Brooklyn. The 1115 Waiver offers a unique opportunity to connect health and social care providers across the State to affect whole person care.
As a Social Care Network and one of only 58 designated community care hubs in the nation, we at Healthy Alliance deeply understand the role a social care referral system plays in effectively connecting community members with health-related social needs (HRSN) to organizations that can help. Throughout our partnership, Unite Us has provided the technology infrastructure for our referral coordination center (RCC) and our network partners, enabling us to successfully connect thousands of people to services, such as healthy food, benefits counseling, housing, primary care, and workforce development, across a broad geography. With Unite Us, our RCC network partners have visibility into screenings, referrals, and case outcomes. Our partnership with Unite Us supports a shared goal and vision to create stronger, healthier, and more connected communities.
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:
In North Carolina, Unite Us has partnered with the North Carolina Department of Health and Human Services to act as the technology backbone connecting health plans, network leads, providers, and public entities engaged in The Healthy Opportunities Pilot. The pilot directs $650M in Medicaid funds to social care through NCCARE360, its statewide care coordination network that is powered by Unite Us.
Since the program launched in March 2022, the partnership has seen an incredible impact, with invoice metrics citing a 2-3% payer rejection rate – compared to the national denials rate of 26% – and over 236,354 services delivered to Medicaid members to date.
To implement SDoH initiatives from Oregon’s previous Medicaid 1115 demonstration, Unite Us partnered with Oregon’s Coordinated Care Organizations (CCOs) to establish screening and referral workflows.
The Unite Us longitudinal care record enables care teams across providers, plans, government, and social services to collaborate securely across sectors and care for the whole person.
Unite Us and Connect Oregon network partner CCOs are working to implement workflows and functionality to reimburse for Medicaid members’ health-related social needs, as approved by Oregon’s 1115 new Medicaid waiver.
As of January 2024:
- The Connect Oregon network offers partners access to over 2,400 accountable, in-network programs.
- 15 of the 16 Oregon CCOs have contracted with Unite Us to provide social care infrastructure to any healthcare provider or community-based organization serving Medicaid members in Oregon.
In Rhode Island, the Executive Office of Health and Human Services offers SDoH screening through our collaborative software, allowing the State and health plans to understand gaps, target resources, and drive plan performance toward equity.
As of January 2024:
- The Unite Rhode Island network offers partners access to nearly 1,000 accountable, in-network programs.
- More than 28,000 managed cases have been seen to completion since 2021, meaning that social or healthcare services have actually been delivered to the client in need.
- Nearly 83% of all referrals are accepted within four days.
Unite Us is supporting an innovative rural healthcare delivery model serving Medicaid members in Missouri. The Transformation of Rural Community Health (ToRCH) project led by the Missouri HealthNet Division of the Missouri Department of Social Services is a new model of care to direct resources to rural communities committed to addressing the ‘upstream’ causes of poor health through integrating social care supports into clinical care.
The ToRCH project establishes community-based hubs that serve as regional leads to direct strategy and coordinate the efforts of healthcare providers, community-based organizations, and social service agencies within a designated rural community. These hubs will holistically address social determinants of health (SDoH) by screening for health-related social needs (HRSN) and connecting Medicaid recipients with select CBOs funded to provide social services. By addressing social needs of Medicaid recipients, ToRCH aims to improve population health outcomes and achieve cost savings. Through Unite Us’ Social Care Payments product, partners will be able to manage eligibility and authorization, send referrals to contracted providers (i.e., close the loop), securely track outcomes and document services, generate invoices, and efficiently manage reimbursement of social care services.
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?
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.