Systems Transformation

With infrastructure that connects health and social care, we can focus efforts on addressing the issues at the root of poor health outcomes.

The Current Landscape

High healthcare costs, bad outcomes

The United States spends more on healthcare than any other country, yet we have poor health outcomes relative to other developed nations.

Compared to other high-income countries, the US spends considerably less on social care than healthcare. Despite our higher investment in healthcare, we consistently have poor health outcomes.

Health and social care spending as a percentage of GDP

Caught downstream

Concentrating interventions within healthcare alone leaves the US caught downstream paying for the consequences of a fragmented system that invests heavily in medical care but not health-related social needs (mid-stream) or community needs and systemic root causes (upstream).

Many efforts to address the social determinants of health have been criticized for only meeting immediate, individual social needs but not extending to the underlying systems in place that are the root cause of the health and social needs. While increased investment in midstream efforts to connect individuals to care within the community signifies progress in the US approach, there is more work to be done moving truly upstream. Community capacity building to redress systemic causes of social needs is vital to achieving true systems change and, ultimately, health equity. State governments play a key role by setting policy convening healthcare leaders, academics, and other stakeholders to discuss ways to improve community conditions and build community capacity.

Public policy should be designed to expand opportunities to deliver services outside clinical settings, including schools and housing projects serving as hubs. Combining such services is common in many developed countries. The United States is the outlier among OECD countries in spending so heavily on medical services relative to social services—and has generally poorer health outcomes.
– Brookings Institute

National momentum building for true transformation

December 2019: NCQA’s new Population Health Accreditation Program⁴ requires screening for social needs

2020: Medicare Advantage plans can provide coverage for a wider variety of non-medical benefits⁵ for chronically ill members

2020: The Social Determinants Accelerator Act,⁶ a bipartisan effort in Congress would provide funding and support for state Medicaid agencies working to implement community outreach interventions to address the social determinants of health.

Buying Health, Not Healthcare

Plans in both states (CA and TX) indicated that the most favorable steps that state government could take would be to support up-front investment (for example, by reimbursing for social determinants–related services and/or allowing social determinants–focused investments to qualify as quality improvements) and to count SDOH investments when setting future health plan rates.
– Health Plan investment survey, Health Affairs

Connecting health and social care

Our system of health and human services is fragmented, and the lack of a common platform for collaboration across service areas hampers our ability to get the most value out of investments in health, human and social services. With infrastructure that connects health and social care, we can focus efforts on addressing the issues at the root of poor health outcomes.

“Those initiatives we are seeing across the country can be large scale like we are seeing with Kaiser Permanente across eight states and the District of Columbia or across an entire state like North Carolina, but you can also see it in smaller markets like the city of Tulsa. It doesn’t matter where you start; you just have to start.”
– Taylor Justice, President of Unite Us

Moving upstream

As a result of the Great Recession of 2008, there were massive cuts to local public health departments across the nation that were never fully restored. For more than a decade, rather than investing in public health and social care programs and building sustainable, resilient infrastructure to connect people to the services they need, our country has chipped away at the very foundation of what should be supporting and sustaining communities. Budgets were cut, personnel were let go, and public health departments across the nation have been scraping by to respond to issues far less dire and urgent than the one we currently face.

It has never been more clear that we need to re-invest in resilient public health infrastructure. Before COVID-19, people in need would end up in hospital emergency departments, not because they were physically ill but because they had no place else to go for help. The pandemic makes that challenging if not impossible. So how do we ensure that people receive the social care and services they need, where they live, and when they need it? And how do we leverage the power of community-based organizations to deliver the best services, closer to people’s homes, holistically in conjunction with our healthcare system?

There are steps we can take now to lay the groundwork for what needs to happen next:

Invest in public health infrastructure (including CBOs) that allows for seamless, cross-sector care coordination and service delivery
Build durable community relationship and protocols for collaboration
Adopt an accountable system to track the distribution of relief funds to grassroots organizations and the outcomes of services provided
Evaluate gaps in services and address equity issues by shifting investments and policy to the communities with the greatest needs
Encourage the federal government to invest in communities on the same scale that it invests in large corporations that are at-risk due to the crisis

We know that investing in an integrated public health system that includes community organizations is the best way to keep people healthy, well, and economically resilient – able to navigate stressful, challenging times. But too often we miss early opportunities to intervene and end up being reactive rather than proactive. Now is the time to plan and implement an immediate response, continue to build and sustain communities as they recover, and strengthen and support them into the future with a well-funded, integrated, and comprehensive public health infrastructure.

Measuring outcomes to build the case for accelerated systems transformation

It is now widely understood that moving investments upstream can improve outcomes and reduce costs, but more research is needed to understand which investments have the most impact. We are just beginning to scratch the surface of understanding the relationship between community resources and the availability of social services on health outcomes. Creating a statewide platform connecting health and social care unlocks a rich new source of data to understand how we can accelerate system transformation and improve lives.

Statewide Social Care Data

Utilizing statewide social care data to enable evaluation of the impact of social service interventions on health outcomes

Community Investment Impact

At the community level, evaluating community investment impact on health outcomes to support shifts in investments to address inequities

Connecting Data Sets

When partnering with state governments, connecting data sets to evaluate the impact of social service investments on other systems (e.g., educational outcomes, employment, corrections, etc.)

Return on Investment

Directing investments to the strategies that have the greatest return on investment

The result of the referral is important to me for more than one reason. Certainly, I want to be sure that the people we’re serving are getting their needs met. And it’s also important to help me understand, as I’m strategically making investments, where to invest. As we’re talking about community benefit, I want to make sure the benefit I put out there is really impactful. The Unite Us platform gave me the opportunity to see where we’re really lacking in our community, so I knew how to drive investment dollars.
– Erin Booker, VP of Community Health and Engagement at ChristianaCare

Ideal State Partnership

Statewide Model

The reason the statewide network is so important to us at Unite Us is that we don’t want to mirror how healthcare built their technology systems. We want to ensure that no matter where a patient, client, member looks for services they can find care but don’t have to tell their story multiple times.
– Taylor Justice, President of Unite Us

North Carolina Case Study

In 2018, the Centers for Medicaid and Medicare Services (CMS) approved North Carolina’s 1115 Waiver to transition from fee-for-service to a managed care program. A critical feature of North Carolina’s approach was the launch of their Healthy Opportunities Pilot Program designed to test evidence-based interventions reducing costs and improving health outcomes by addressing housing instability, transportation insecurity, food insecurity, interpersonal violence and toxic stress for eligible Medicaid beneficiaries.

In Spring 2019, Unite Us partnered with the Foundation for Health Leadership & Innovation (FHLI) and the North Carolina Department of Health and Human Services (NC DHHS) to launch the nation’s first statewide coordinated care network, connecting health and social care providers using the Unite Us platform and supported by our local team members. Key NCCARE360 partners also include United Way of North Carolina, NC 2-1-1, and Expound Decision Systems. As a result of this groundbreaking public-private partnership, over 4500 providers from over 1000 organizations have joined the network to provide care to people in need.

“As we seek to create a health care system that truly rewards value, we must consider the impact that factors beyond medical care have in driving up health costs. That’s why many states are beginning to think about ways to better address the root cause of chronic illness. As part of this demonstration, North Carolina will implement a groundbreaking program in select regions to pilot evidence-based interventions addressing issues like housing instability, transportation insecurity, food security, interpersonal violence and toxic stress.”
– Seema Verma, CMS Administrator

Statewide Model Playbook

How did North Carolina do it?

Supporting Priority State Initiatives

Our work at Unite Us started in the veteran services arena and expanded to include all populations, with a particular focus on addressing social determinants of health. But the opportunity for impact does not stop there. Agencies throughout government struggle with similar challenges -- a fragmented array of services and programs and difficulty collaborating to wrap services around individuals in need. Our Unite Us Platform can support a wide range of initiatives to advance governments’ strategic goals.

Research shows that there are numerous opportunities to improve outcomes and achieve cost savings by focusing efforts on populations that receive a high level of services across multiple service sectors.

Multisector Action as a Tool for Efficiency and Health System Sustainability

High utilizers of healthcare services are also high utilizers across:

Health care and non-health care expenses per person per year for Medicaid expansion enrollees with and without high health care use

Source: Diaz Vickery et al. Cross Sector Service Use Among High Health Care Utilizers in Minnesota After Medicaid Expansion. Health Affairs 27 No 1 (2018)

This means there's an opportunity for cost savings across sectors if social and behavioral determinants can be addressed collectively and points to a need for a multisector approach to addressing high utilizers and social needs.

Veterans

Founded in 2013 by two US military veterans, Unite Us was originally built to create a coordinated care network to ensure that veterans get access to the services they need. Since that time, we have expanded beyond the veteran community but remain deeply committed to developing coordinated care networks across the country for the veteran community.

Criminal Justice Reform

Creating centralized infrastructure that coordinates care and supports diversion and reentry initiatives to break the cycle of mass incarceration that costs governments billions of dollars with poor outcomes for communities and justice-involved individuals.

Learn how Unite Us supports justice-involved populations →

We serve some of the most vulnerable people through our re-entry program that provides referrals and resources to people coming out of correctional facilities, the homeless community, victims of domestic violence, and substance abuse. It is critical that we get them set up on the right foot, but we were struggling to connect our clients to outside services without a gap in care,” said Avon Curtis, executive director, Arms Around You. “When we connected to the Unite Us platform, it alleviated any confusion and helped us better support the goals of our clients. The platform minimizes the heavy lifting by holding both the referring agency and the organization accepting the referral accountable to follow-up with the client. Unite Us is what community -based organizations need to bridge the gap!
– Community Health Plan of Washington, Unite Us Partner

Adverse Childhood Experiences

Supporting efforts at detection and early intervention of adverse childhood experiences (ACEs) and providing a platform for referrals and coordination of services and treatment.

Maternal Health

Reducing racial disparities in maternal and early childhood health by partnering with states, health systems, and local organizations to coordinate care that addresses the social determinants of health for pregnant women and mothers with young children.

Learn how Unite Us supports equity in maternal and early childhood health initiatives →

Substance Use Disorder

Screening for co-occurring physical, behavioral and social needs and providing an accountable, coordinated ecosystem so the community is prepared to provide support for individuals on the path to recovery.

Social Isolation

Supporting innovative models to ensure that older Americans and others who are socially isolated are receiving the services that they need to remain healthy and thrive.

Education

Creating coordinated networks to ensure that school-based employees have the support they need to address problems identified in the school setting and connecting students and families to community resources and tracking outcomes of services rendered.

Learn more about System Transformation at Unite Us

See All

Unite Us Blog Forum filled of industry news, content, strategy, and thought leadership.

Applying CMS' Community Health Access and Rural Transformation (CHART) Model to Bolster Health
by Megha Poddar on January 6, 2021 at 3:52 pm
Amid a growing recognition that rural communities have inequitable access to services, any reform should build upon existing community infrastructure and include participation from all health, human, and social service leaders. Improved collaboration between rural communities and health systems accelerates innovative solutions, and has the potential to create more sustainable and equitable healthcare system transformation. It’s important that innovations and policies are informed by the communities they serve, so they more likely meet rural regions’ unique needs, and support residents who have long suffered from inadequate resources and disparate health outcomes in comparison to their urban counterparts.
The Impact of CARES Act Funding Nationwide and in St. Louis: Early Data Trends
by Kelly Binder on December 17, 2020 at 2:25 pm
Data from the Unite Us network in St. Louis shows the growing demand for rental and mortgage assistance. Demand is high – leading us to ask if CARES Act funding alone is enough and what other services need investment.
Putting Children’s Needs First: Building Coordinated Care Networks to Improve Outcomes
by Samantha Adelberg on December 9, 2020 at 2:05 pm
At Unite Us, we know advancing children's health requires that we consider their overall well-being. This means assessing health not just by the absence of disease or premature mortality, but also by a child’s ability to thrive. It requires that we seek to address the full range of complex historical factors and community conditions that influence children's biological, behavioral, social, and physical environments.
Positive Data Trends Amidst a Global Pandemic
by [email protected] (Brooke McConnell) on October 7, 2020 at 1:21 pm
Despite the national impact of a global pandemic, we have seen a positive trend in growth and impact in our statewide network in North Carolina, NCCARE360.
Partnering with Government to Transform Care
by [email protected] (Brooke McConnell) on September 9, 2020 at 2:19 pm
The path to healthier, more equitable, and resilient communities requires an integrated and coordinated approach to meet health and social care needs. In turn, a move to transform our current health and human service system, with an upstream focus on prevention and investment in health and not simply healthcare, requires meaningful collaboration and authentic public/private partnerships.

Sources

¹ Moody’s Analytics, Understanding Health Conditions Across the U.S. BlueCross BlueShield Association. December 2017.

² Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA, October 2019.

³ Centers for Medicare & Medicaid Services, National Health Expenditure Fact Sheet, 2018.

⁴ https://www.ncqa.org/programs/health-plans/population-health-program-accreditation/#:~:text=NCQA%20Population%20Health%20Program%20Accreditation,and%20challenges%20in%20their%20populations

⁵ https://www.rwjf.org/en/library/research/2019/09/are-medicare-advantage-plans-using-new-supplemental-benefit-flexibility.html

⁶ https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2019.01246