Data Series

Medical and Social Care Network powered by Unite Us Demonstrates $320,000 in Annualized Medicaid Savings in Under Six Months

As basic food insecurity screening is rolled-out in medical settings, healthcare providers need to feel confident that patients can be connected to the food nutrition services that best meet their needs. With no coordinated, risk-stratified intake and referral system for nutrition, inappropriate referrals (or no referrals) to community-based services are common.

The FNS Bundle solves this multifaceted issue. The project has successfully streamlined referral processes by drawing on nutrition provider expertise to create an assessment and risk stratification tool, embed it into Unite Us, allowing partners to screen patients for food insecurity and nutritional risk, send secure electronic referrals to food and nutrition resources, enroll patients in a range of nutrition interventions, and track outcomes and data about service delivery to evaluate the program’s effectiveness.

Now, let’s dive into what they’ve discovered so far.

$320,000 in annualized Medicaid savings were demonstrated by tracking every outcome delivered by network partners

By tracking every outcome delivered, FNS Bundle agencies were able to see that of all patients enrolled, 30% were enrolled in SNAP, 27% received emergency food, and 4% received medically tailored meals. Using studies of SNAP and Medically Tailored Meals’ annualized savings to Medicaid, partners projected $320,000 in Medicaid savings per year for those enrolled in the project so far.


1. "SNAP Is Linked with Improved Nutritional Outcomes and Lower Health Care Costs," Center on Budget and Policy Priorities

2. "Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries," Health Affairs

Real-time data was used to close a 33% service gap

71% of patients screened reported a need for emergency food, which was significantly higher than initially expected. However, there was only a 38% enrollment rate for emergency food, indicating that the network itself did not have enough emergency food providers to match the demand. As a result of tracking enrollment outcomes and referral data, PHS doubled the number of emergency food providers to fill the 33% service gap in their community.

90% of electronic referrals were accepted by community providers upon first receipt

Of all the referrals in the network, 90% were accepted meaning the receiving agency received the referral and contacted the participant. This indicates that 90% of the referrals sent included eligibility criteria to ensure they were sent to the proper program. The improved efficiency of the referral process supported individuals to access the help they needed in a timely manner.

Patients are simultaneously being served by two or more community providers

PHS tracked an average of 1.9 referrals per person, indicating that multiple providers delivered different services to the same person at the same time. Not only was PHS able to track patients’ co-occurring needs through Unite Us, but they were also able to ensure that those co-occurring needs were being addressed.

Watch Zachariah Hennessey of PHS discuss the impact of the data tracked through Unite Us:

Note that this video was filmed on April 3rd, 2019, but the updated data as of April 29th, 2019 is reflected in this series.

"We were able to take action in direct response to [the community's] needs." – Zachariah Hennessey

Prior to partnering with Unite Us, community nutrition providers already had strong relationships but lacked the infrastructure to connect to healthcare and track service outcomes. Through Unite Us, the FNS partner agencies were able to demonstrate $320,000 in annualized Medicaid savings, fill a 33% service gap, and improve coordination efficiency.