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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.

Table of Contents

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.

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).

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

Connecting health and social care

“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

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:

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.

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

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

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.)

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

Ideal State Partnership

Statewide Model

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.

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.


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.

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.

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.


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

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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.