Unite Us Live: Building Stronger Communities With CommunityCares

Hi, everyone. I’m so excited for today’s conversation. I hope everyone is having a good day. We’re going to give it a few minutes for folks to jump in, and I’m excited for Artemisa and Kelly to talk about their programs. I’m especially excited that today we have a 40% chance of rain, and we’re getting ready for monsoon season, so we hope to get it this year. How are you both doing today?

I’m doing great. We have a 0% chance of rain. I’m in Phoenix, Arizona.

Oh, man. I’m sorry to hear that.

Doing well. Thanks for the opportunity to be here today.

You’re welcome. Alright, so we’ll give it a few more minutes.

Okay. We’re going to go ahead and get started. Hi, everyone, and thank you for joining us for Unite Us Live: Building Stronger Communities with Community Cares. I’m Mayra Dominguez, community strategy enablement manager at Unite Us, where I work in Arizona helping to onboard, train, and recruit community-based organizations to Community Cares, with a particular focus on expanding participation and access in rural communities. Prior to working in this role, I spent six years at a nonprofit dedicated to early childhood education and prevention. So shout out to all my early childhood educators.

Today, we’ll be talking through the story of Community Cares, Arizona’s closed-loop referral network powered by Unite Us. We’ll hear directly from two leaders involved in building and sustaining this care coordination network into 1,500 participating organizations serving more than 113,000 individuals statewide.

First, we will have Kelly McGann, director of social determinants of health at Contexture, Arizona’s health information exchange and oversight agency for Community Cares, where she oversees the Community Cares program. Kelly brings experience working across health and human services with community-based organizations, bringing a strong focus on the human element of SDOH interoperability and building the tools and resources with the community voice at the forefront.

We’re also joined by Artemisa Martinez, executive director for Valley of the Sun YMCA, a community-based organization participating in Community Cares with a 97% acceptance rate and a 99.7% resolution rate, which, by the way, is a huge accomplishment. With nearly 25 years of experience in social services and public service, Artemisa leads operations at the Lincoln Downtown YMCA and oversees programs including transitional housing, food assistance, workforce development, and veteran services. She’s also passionate about building community partnerships and creating programs that support Arizona’s most vulnerable populations.

So thank you both for being here. How are you today?

Very good. Thank you for having us.

You’re welcome. So to kick us off, Kelly, can you give us a little background on Community Cares? What need did the network aim to address, and what helped build momentum and buy-in across organizations statewide?

Okay. Yeah. I’m going to try and cover a lot of background in just a few minutes, but I’m always happy to expand because there were a lot of starts and stops and process refinement along the way.

Community Cares, as you mentioned, is Arizona’s closed-loop referral system, and it is part of Arizona’s Medicaid agency, which we call AHCCCS, and their Whole Person Care Initiative. So moving forward, when I say AHCCCS, just know that means Medicaid. AHCCCS recognized that in order to improve members’ health outcomes, you also needed to address their social determinants of health, or some call that their health-related social needs.

They also realized that by asking providers to address the SDOH or health-related social needs of their members, AHCCCS needed to provide a tool to help those providers make connections to community-based social services. Through their investment in the program, both our CBOs and health care providers are able to access Community Cares, which is powered by the Unite Us technology, at no cost to those organizations.

So this was able to establish a single technology solution that enables providers across different sectors to connect to address the health-related social needs for their patients and their members. It’s important to understand that this is a true partnership among many organizations, so I’m going to try and just sift through the different partners and their roles in this work. But of course, it’s a partnership of our organizations, of Medicaid, but also the community and private providers who are enabling the successful network.

Community Cares is the program. As we mentioned, it’s a statewide closed-loop referral system across the whole state of Arizona. AHCCCS, as our Medicaid agency, is making the investment to address health-related social needs across the entire state, providing access to this program and to the technology at no cost.

Contexture, which is my organization, is the program administrator. We are responsible for engagement, recruitment, implementation, and then providing post-live support and technical assistance along the way. We partner really closely with the Unite Us team to do all of those steps. Unite Us is the technology solution and the platform that enables the network across Arizona.

Then we partner really closely with Solari Crisis & Human Services in a variety of ways. They provide and maintain access to a statewide resource directory that we ingest and enable on the platform, and they also administer programs like the Health and Housing Opportunities Program.

So that’s the background of the program. Shifting to some of the buy-in and momentum, I think it’s important to acknowledge that this is really hard work for so many reasons. We’re asking providers with limited capacity to adopt a new workflow, and that’s really challenging. There’s limited funding and availability within our community resources, and CBO capacity is a concern.

While we’ve made really impressive strides in Arizona, I think it’s important to recognize that we still have a lot of work to do, especially within our rural communities. What I really want to highlight, though, and what I think has been critical in our success, is that throughout our efforts, we have been working within communities.

We’re out across the state. We’re in person, and we’re working to understand who the right organizations are in each community that we should be engaging with, what is important to them, and what the goals of that community are. Then we’re thinking through how we can support each organization and community in meeting their goals.

We’re not taking an out-of-the-box solution and rinsing and repeating. We’re really determining how we can customize the Unite Us platform to be able to meet the individual needs and workflows of each organization. Then we provide opportunities for feedback. We listen. When we hear barriers, we try to solve for those. If we’re not able to find a solution, we’ll advocate for the changes that are needed. Maybe it’s a platform enhancement so that we can be successful. I think that individualized support has really been critical in engaging organizations and optimizing utilization.

Thank you for sharing, Kelly. I really do agree with what you’re saying about individualizing that support because each organization is different, and each need is different. So thank you for sharing your insights.

Speaking of organizations, Artemisa, from the perspective of a community-based organization like the YMCA, how has being part of a connected network changed the way your team approaches care coordination? And what difference has it made for the people you serve?

As a community-based organization, being part of a connected network has fundamentally changed the way we approach care coordination because, in the past, connecting clients to resources often relied on phone calls, emails, and even, way far back in the day, fax machines. While those connections were valuable, it was difficult to track whether individuals actually received the services or to coordinate care across multiple providers.

It definitely has been very impactful in that way. We’re able to track the referrals that are coming in and going out and the actual results. It’s very important to have the case note components for our providers to see what communications we have had with the clients and if there are follow-ups needed on their end, or if we’ve uncovered any other barriers that we can refer over to other organizations.

Through the connected network, we’re able to make those referrals more effective, communicate with all of our partner organizations in real time, and gain visibility into the outcomes. Time is what’s most critical for us as providers. Most of the time, we’re addressing critical needs. Somebody has nutrition assistance needs. Somebody has a housing need. Those are things that usually can’t wait, so addressing them in real time is super important.

It allows our team to focus less on navigating those systems as providers and more on supporting the actual individuals that we’re serving. For the people that we’re serving, the impact is significant. We’ve been able to touch many people that we weren’t able to in the past. Just last month in May, our organization, and this is just our anti-hunger food pantry efforts, served 1,654 people, and the majority of those referrals came from Unite Us.

The reason we’ve been able to have such a high acceptance and resolution rate is because answering these critical needs in a very short amount of time and addressing those needs helps you become trusted within the community. Many of our clients are facing multiple barriers at the same time, including housing instability, unemployment, food insecurity, transportation challenges, and all those different things.

This connected network helps ensure that they can access multiple services more quickly, and it reduces the likelihood that they’re going to fall through the cracks. At the Valley of the Sun YMCA, we’ve seen how these coordinated referrals have strengthened our partnerships, improved service delivery, and created a seamless experience for the client internally and externally.

Ultimately, it allows us to better address the whole person, not just a single need. It helps individuals move more quickly toward stability, self-sufficiency, and long-term success, and that makes our communities healthier. We are just so grateful.

Thank you, Artemisa. It’s so nice to hear that you have helped so many people through the platform. I could totally relate to you with keeping track of all the resources in the community. I feel like it’s impossible, especially statewide. So thank you for sharing.

I would love to get some quick thoughts from both of you for our last question. A lot of communities are trying to grow networks like Community Cares but struggle with sustaining engagement. What’s one piece of advice you would give for building a network that’s both scalable and sustainable long term?

I can jump in here. As the program administrator, Contexture is looking at this from a systems perspective. In our work, it’s really critical to seek alignment and buy-in across the sectors involved in this work really early on, and then identify ways that we can support multiple state and community initiatives. I think that has led to some of the success that we’re seeing within the Arizona network.

Within Arizona, again, due to the AHCCCS investment, we are able to provide licenses to the Unite Us platform to all of our participating organizations at no charge. Of course, there are staff costs and training costs, but access to the platform is at no cost. What we’re seeing is that dollars can go further.

In Arizona today, there are multiple state programs across state departments leveraging Community Cares as a statewide infrastructure to meet their aligned but maybe differing goals. I wanted to highlight a couple of examples where we’re seeing the state alignment really allow us to go further and faster in our work.

An example I can share is the Solari program that I mentioned earlier. They’re the program administrator for AHCCCS’ Health and Housing Opportunities Program, which we call H2O. They leverage the Unite Us technology to connect their Medicaid members to housing services. Then they’re able to incorporate expanded functionality so that those community housing providers can capture data and generate invoices so they’re able to submit for Medicaid reimbursement. All of this is utilizing the Community Cares infrastructure.

Another example is with our partnership with the Arizona Department of Health Services. We partner with them and support their diabetes prevention and education programs. Again, they’re utilizing Community Cares and Unite Us as the infrastructure and the technology to stand up a diabetes referral network.

What we’re able to do here is that instead of all of these programs starting from scratch, they are able to leverage and build alignment. We’re seeing state agencies and communities really buying into this statewide alignment, utilizing the Community Cares infrastructure as the foundation to meet their housing mission and goals for the H2O program. We’re also seeing in Cochise County that they’re really utilizing the infrastructure to address food insecurity within their community.

We now have this centralized source of social care data that we can utilize to make program decisions, better identify gaps across the state, and share the data that we’re seeing back to state agencies so they can make important program and policy decisions. I think that alignment and buy-in allow us to be scalable and allow dollars to go further.

Thank you, Kelly, for explaining how Unite Us and Contexture work together, and for the insights that you have of everything that’s happening and how impactful it is to have this data, not just for Arizona, but for organizations as well.

Artemisa, do you have anything to share?

Yes. I would say my biggest piece of advice is to focus on the relationship before technology. The technology is wonderful. It’s been mastered, right? But the platform can only facilitate connections. The people sustain the network. Organizations need to see the value in participating, trust that their referrals are going to be acted upon, and feel that they’re part of this shared mission for the clients that we’re serving.

For the network to be scalable and sustainable, the partners must remain engaged. I think that through consistent communication, collaboration, and feedback, we need to celebrate successes, share impact stories, and regularly demonstrate how participation is improving outcomes for all of the clients and reducing duplication of services, which in the past had been an issue.

The impact stories are actually what are going to help some of the other people in the community who have not had success navigating systems before. The impact shows the real-life connection. At the Valley of the Sun YMCA, we’ve found that engagement grows when partners understand that they’re not simply making referrals. They’re part of this coordinated system where we work together to address complex community needs.

I think when organizations see real outcomes for the people that they serve, they become invested in the network’s success.

Thank you for sharing, Artemisa. I completely agree with you that it has to be very personable and have that human element. So thank you for that insight.

Thank you all for joining us today, and a huge thank you to both Kelly and Artemisa for joining us and sharing your insights. It’s exciting to hear how collaboration, shared goals, and the right tech infrastructure can help communities build stronger and more connected systems of care.

If you’d like to learn more about Community Cares or join the network, you can visit our website or learn more about upcoming events in the chat below. Thanks again for spending part of your lunch break with us, and we’ll see you next time at Unite Us Live.