The Transformation of Rural Community Health
ToRCH, a rural health program from Missouri Medicaid, directs resources to rural communities tackling the root causes of poor health. By integrating social care into clinical care, ToRCH aims to improve outcomes, better use existing funding, and create sustainable paths for rural hospitals while helping individuals manage chronic conditions.
Unite Your Network with an Integrated Social Care Platform
The Unite Us platform brings together your existing network of community partners to facilitate referrals, track outcomes, and improve community health. By joining Unite Missouri, you will have free access to the tools, partnerships, and resources to amplify your impact and streamline care coordination.
Maximize Your ToRCH Impact with the Unite Us Platform
The ToRCH model is driving impact by connecting eligible clients to the service providers that can meet those needs. Over 400 programs are available on Unite Us across the 6 ToRCH counties resulting in more than 1,340 clients being served.
400
programs
are available to support ToRCH community member needs
100%
Case Acceptance Rate for Programs
ToRCH providers are meeting the critical needs that eligible clients are seeking, strengthening the ToRCH model
1,200+
Clients Served
ToRCH partners are impacting the lives of their community members
ToRCH Eligibility
Requirements
In order for a patient to be referred to one of your contracted community providers that are providing one of the (b)(3) services, they must meet the following eligibility criteria.
- Enrolled in Medicaid: Verification of active Medicaid member with one of the Missouri Medicaid health plans (Healthy Blue MO, UnitedHealthcare MO, Home State Health, Show Me Healthy Kids, or straight MO HealthNet)
- Hub County Resident: The member must be a resident of one of the six participating hub counties (Pettis, Polk, Henry, Phelps, Dent, & Ray Counties). This will be confirmed as you’re enrolling the patient in Social Care Coverage in the Unite Us platform.
- Screen Positive for a Health-Related Social Need: Each hub has a different screening process.
- Medical Diagnosis: The member should have a clinical diagnosis or relevant medical need that is impacted by the HRSN
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Medicaid residents of each ToRCH county who screen positive for food insecurity and transportation insecurity who are pregnant, postpartum, and/or have a diagnosis of obesity or overweight, diabetes or pre diabetes, hypertension, or kidney disease.
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Medicaid residents of each ToRCH county who screen positive for transportation insecurity.
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Medicaid residents of each ToRCH county who screen positive for housing problems to address safety risks like ramp installs, grab bars, etc.
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Medicaid residents of each ToRCH county who screen positive for housing problems and who have a diagnosis related to breathing difficulty, such as asthma, COPD, emphysema, etc. Services may include: mold removal, dehumidifier purchase, A/C window or wall unit installation.
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Medicaid residents of each ToRCH county who screen positive for food insecurity and who are pregnant, postpartum, and/or have a diagnosis of obesity or overweight, diabetes or pre diabetes, hypertension, kidney disease or other diet related chronic conditions.
Ready to Take the Next Step by Getting Involved with ToRCH?
Are you a community member who needs help?
Are you a resident of Pettis, Polk, or Ray county and are in need of services?
Frequently Asked Questions:
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The ToRCH program is powered by Unite Us, a national leader in software enabling cross-sector collaboration to improve people’s health and well-being. Through Unite Us, 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, efficiently manage reimbursement of social care services, and connect activities back to improved health outcomes.
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- A Priority Partner is a community based organization (typically a 501c3 nonprofit) that provides services in at least one of the 6 ToRCH counties (Dent, Polk, Pettis, Phelps, Henry and/or Ray County) that will use Unite Us closed-loop referral platform to send or receive electronic referrals. By receiving referrals from the Hubs or partners, priority partners strengthen the ToRCH network by addressing client residents’ social needs (food, housing, clothing, mental behavioral health, utility assistance, etc). Priority Partners use Unite Us’ closed-loop referral functionality to receive or send referrals.
- A B3 Contracted partner provides services in at least one of the 6 ToRCH counties that fall under the eligible services. These services include: non medical need transportation, medically tailored meals, nutritional counseling & education, environmental modifications to the home (ramp / grab bar installations), environmental goods and services (mold removal, pest control). A Contracted Partner will use Unite Us to receive electronic referrals sent by the Hub for clients that are eligible for that ToRCH service. The Contracted Partner will use Unite Us’ Payments Solution functionality to document the service in Unite Us and send an invoice to the Hub to receive reimbursement.
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- If your organization provides non-emergency health related transportation, medically tailored meals, nutritional counseling & education, and/or is a licensed general contractor experienced with mold/pest removal, plumbing, heating & cooling, you may be eligible to be a ToRCH B3 contracted partner.
- Your organization must serve community members from at least one of the 6 ToRCH counties (Dent, Polk, Pettis, Phelps, Henry, Ray County).
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ToRCH eligibility requires verification of Medicaid enrollment and insurance as well as completion of SDOH screening to determine Health Related Social Needs. Lastly, a patient must have a medical diagnosis that is directly impacted by the HRSN. Due to these requirements, only clinical care organizations (hospital, clinic, FQHC, behavioral health, county health departments, etc) have the ability to enroll a community member in ToRCH social care coverage in Unite Us.
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- Authorization must be approved by the Hub for some of the ToRCH programs based on the ToRCH clients’ needs.
- ToRCH programs include: medically tailored meals, nutritional counseling & education, environmental modifications to the home, and environmental goods and services. The required authorization will be included in the referrals sent to the contracted partners.
- The authorization will inform the contracted partner of the amount of service approved by the Hub that the contracted partner can provide. The authorization will also include the service delivery dates that the contracted partner will provide services to the client.
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- Dent County – Salem Memorial District Hospital – Salem, MO
- Henry County – Golden Valley Memorial Healthcare – Clinton, MO
- Pettis County – Bothwell Regional Health Center– Sedalia, MO
- Phelps County – Phelps Health – Rolla, MO
- Polk County – Citizens Memorial Hospital – Bolivar, MO
- Ray County – Ray County Hospital – Richmond, MO
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No, there is no cost for your organization to participate in ToRCH and join Unite Us to send, receive and manage referrals.
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You control your information. Unite Us developed a robust consent process to prioritize privacy, health equity, and accessibility. Read our privacy policy to understand better how your information may be shared
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Unite Us’ Technical Support team is ready to assist you with software inquiries and technical issues. There are several ways to connect with our team:
- Email: Send your questions directly to our Technical Support team for prompt responses and consultations.
- Live Chat: Engage with a Technical Support team member in real-time via live chat, accessible in the bottom right corner of the Unite Us Platform, even if you’re not logged in. The chat window also provides access to Help Center articles and allows users to download the Unite Us consent form in over 50 languages.
- Phone: Call the Unite Us support line for assistance.
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We offer live webinar training during implementation before the launch of the network and one-on-one meetings with CBOs for workflow planning and onboarding on a case-by-case basis.
Post-launch, all users have ongoing opportunities to enhance their Unite Us knowledge. Our team hosts live, regularly scheduled, standardized new and advanced user webinar training where participants can dive deeper into our platform’s features. In addition, the team manages a robust e-learning catalog where users can complete on-demand courses at their own pace. Finally, users will have access to downloadable user guides that describe the main features and workflows in our platform.
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We have implemented hundreds of integrations with EHRs, HIEs, and other systems of record, such as ZeOmega, Salesforce, NextGen, Epic, VirtualHealth, Cerner, Meditech, and eClinicalWorks, including the nation’s first native social care integration in Epic that incorporates structured outcomes. These integrations provide mechanisms for data exchange that leverage industry standards, including single sign-on (SSO), HL7, APIs, and file exchange.
Our platform captures outcomes and does not require integrations to fully “close the loop.” Workflow and system interoperability is a powerful enhancement to the user experience and aids user adoption. Our platform is built on modern architecture, APIs, industry-standard development practices, security, and data exchange capabilities to drive continued innovation alongside seamless adaptability and scalability. We will work with [Customer Name] to integrate into your existing workflows and systems while providing capabilities to continue innovating in your future enterprise architecture.
For additional Frequently Asked Questions, visit the Missouri Department of Social Services ToRCH webpage.