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How One Social Care Provider is Opening New Doors for Vulnerable Populations


Molly Blumgart

Unite Us exists because we believe individuals and families in need should be able to easily navigate and access the robust services and resources in their communities. As our partners across the country have demonstrated, one of the best ways to achieve this is to ensure trusted service providers across a community have the necessary infrastructure and support to create a cohesive, collaborative system to ensure clients get connected to the services they need – what we call “coordinated care networks.” These networks build accountable relationships between partners in a community by allowing them to openly communicate about their clients’ barriers to access and to stay up-to-date on the journey of their clients’ referrals and needs outside of their four walls.

When building these networks, a core question drives our work:

“Does what we’re building meet the needs of this community and will it set our community-based organization partners up for success?”

We’re working with organizations tackling some of the most complex inequities and health disparities in their communities, and many of them are doing incredible work with limited resources – their time is precious. We want to make it as easy as possible for partners to efficiently connect their clients to appropriate services so they have more time to do their core work and provide desperately needed services. Our partners know that by developing these relationships and working as part of a coordinated care network, they’re able to significantly impact the health and stability of their community and its members.

In the Unite Us-powered Healthy Together Referral Network in upstate New York, Alliance for Better Health is leading the charge in building these accountable relationships between their partners in a community. To learn more about what this looks like on the ground and how social service partners leverage our platform, we talked to Jason Chaplin, Housing Stability Advocate at St. Paul’s Center. St. Paul’s Center is a nonprofit organization providing emergency housing for homeless mothers and their children in Rensselaer, New York, and is a partner in the Healthy Together Referral Network. As described so beautifully by Jason: “St. Paul’s Center is a community that strives to awaken hope and rekindle dignity in families who seek comfort, support and assistance in moving from homelessness to a sustainable future.”

Here is what he shared with us.

What are some of the biggest challenges your organization faces regarding connecting your clients to other resources in your community?

The amount of time it can consume. For me, [the biggest challenge] was always being the “middle” person. I would call around to organization after organization. I would literally look through a Rolodex that the Housing Stability Advocate left behind, use Google, use coworkers’ resources, etc. hoping to find a resource. More often than not, I was not successful. I would, for the most part, have to rely on internal resources, i.e. donations or volunteers, to help the families in need. I was never very successful in getting financial assistance for clients until I began using Unite Us. That is a big change. I’ve had several families receive financial assistance with eviction prevention, past due National Grid bills, and storage payments to name a few. Not to mention all of the advocacy work the referrals have produced.

How has Unite Us addressed some of these challenges? Have we improved your efficiency or day-to-day workflow?

Unite Us has saved me vast amounts of time and has made the referral process much more efficient. After sending a referral for a family after a home visit, more often than not, the family will get a call from someone in the network that day. The families we serve have been very responsive. They like that they do not have to wait for me to hear from person “A” to call me back so I can let them know what they said. It’s great to not have to be the “go between”. The families really like that, too. They like the fact that they talk directly to the person who may be able to assist them.

Why do you think it’s so important for your organization and other social service organizations to have access to a tool like this?

It’s such a vast networking tool. It would be impossible to have the connections to as many organizations and services as Unite Us can link us up with. It goes back to the time consumption. Even if my “network” was as large as the Unite Us database of organizations, I would not have enough time in the week to reach out to them for the number of families in need that we serve. With Unite Us, the referral is sent from organization to organization seamlessly. It has been very efficient for myself and the families we serve.

How has this changed or improved relationships with your partners in the community? What does that mean to you and how does it relate to your mission?

It has improved my relationship by opening doors I did not know existed. I am now aware of organizations and services they offer that I was not previously aware of. It has helped in relation to our mission by providing extra support. We can now provide extra support due to this referral system. There are times in the past that I would not be able to assist a family due to time constraints or the inability to get transportation if I was not available. I can help provide assistance now as easy as a five-minute referral through Unite Us. The families we work with have very limited resources. When they call me, at times I’m their last/only resort. Things have seemed to change since I’ve begun using Unite Us. The turnaround with the referrals happens so quickly, most families do not hesitate to reach out to me for a referral. It is great to work with families that have that comfort level. Despite what public perception may be at times, the families we work with do not want “handouts” and most times they are hesitant to ask for help. When a family calls and asks for a referral, I feel that a major barrier has been removed. I have honestly noticed this change since incorporating Unite Us into my job. Previously, the clients would feel like they were “bothering” me. I don’t get that comment as much anymore.

How do you envision this approach to coordinating care impacting your community in the future?

I have hopes that all agencies will begin to use Unite Us. I promote Unite Us and Circulation everywhere I go. I have had folks at the START center ask me how to get information. At other agencies that do not use the referral system, I have stressed how valuable it is. The more agencies on board, the more we can provide for families in the community. Ultimately we are all working toward the same goal, ending homelessness. We should be sharing our resources and working on “Housing First” regardless of which agency has the ability to assist the family at that time. Getting the assistance for the family is what is important. Funding is always an issue for our agencies, but something tells me it will always be an issue. Sharing resources is the best way to approach it in my opinion. Unite Us has created a place for us to pool our resources.

How do you envision this approach having an impact beyond your community?

I am already starting to see an impact beyond my immediate community. I have had families who live in other counties receive assistance through Unite Us referrals. The amount of interest people tend to show when I talk about Unite Us gives me hope that this is a system that will branch out from community to community and agency to agency. It is such a valuable tool. It forces us all to work together. Pooling resources is a great thing. I would love to see the pool get bigger and bigger. The more agencies that sign on, the more people we can serve. As I’ve stated several times, the network has saved me so much time. The more it grows, the more time agencies will save. That means more people can receive assistance.

Tremendous thanks to Jason for his thoughtful words, to St. Paul’s Center for upholding such a compassionate mission, and to Alliance for Better Health for leading the Healthy Together network that brought us all together.

To learn more about how we’re redefining the social care delivery system:

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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.

Topics: Health for All