When a patient goes to the doctor with a serious complaint, what if the cause is not a medical issue? What if someone’s diabetes is spinning out of control because they can’t afford healthy food, or their asthma is acting up because their apartment is moldy?

Unlike an infection or a broken bone, clinicians can’t fix social needs with a simple prescription or procedure. Imagine having a patient who can no longer afford to pay the rent. Do you refer them to a government program? Or to one of the dozens of nonprofits that might help? And how do you find out if any of those programs actually helped?

More health systems are recognizing the role that social factors can play in driving poor health outcomes, and many are taking steps to address them. Recently, 14 leading health systems, including Kaiser Permanente and CommonSpirit Health, announced a collective investment of $700 million to address the “root causes of poor health” in the communities they serve.

At the same time, health systems are recognizing that the decentralized nature of community resources can undermine investments made with the best of intentions. When those resources are fragmented and hard to navigate, they can frustrate and fail both providers and patients and make it more difficult for patients to access the care they need.

A Fragmentation Fix

Health systems like CommonSpirit Health and Kaiser had long believed that technology could help fix that fragmentation problem, but the available tools were limited and hard to scale because social services are hyperlocal. Both organizations believe they’ve finally found the kind of scalable solution they were looking for — a New York–based company called Unite Us.

Other large health systems, insurers, and investors seem to agree. The array of customers of Unite Us includes organizations like CVS and the North Carolina Department of Health and Human Services. The company has raised $35 million from major investors and recently received a program-related investment from CHCF this fall. Unite Us now operates in 23 states, including California, where it is focusing rollout efforts in Kern, San Joaquin, Merced, and Los Angeles Counties.

Creating a Two-Way Street

While other efforts have made strides in addressing social needs, Unite Us believes they offer an unprecedented pairing of dynamic technology and deep community engagement. When it comes to their technology, a key differentiator is that any participating organization can be both an initiator and a recipient of referrals. If, say, a food pantry client brings up a housing issue, the pantry can log on to Unite Us and refer the client to a housing resource. Similarly, if a client complains of symptoms that sound like prediabetes, the food pantry can refer that person to a primary care provider on the Unite Us network.

“People’s needs come up in a variety of places,” said Ji Im, senior director of community and population health for CommonSpirit Health, a Chicago-based health system that owns 30 hospitals in California. “We don’t only want to address social and economic needs once someone is sick. That’s too late. We need to be more proactive.” Health systems also recognize not all patients are comfortable sharing their nonmedical needs with a health professional  —another reason to empower a large number and diversity of community partners.

We don’t only want to address social and economic needs once someone is sick. That’s too late. We need to be more proactive.

—Ji Im, senior director of community and population health for CommonSpirit Health

CommonSpirit Health also hopes that those outside organizations will help ease an unrealistic burden that has fallen largely on primary care providers. “These providers have about 15 minutes to understand all of a patient’s medical history and needs,” Im said. “To expect them to also address all of their social needs — that’s unattainable.”

Unite Us participants can see which other organizations a client has been referred to and what the outcome was so that they avoid sending a client down an unhelpful path. That transparency helps refine future resource recommendations made by both the Unite Us search engine and participating organizations.

Making a Data-Driven Difference

So what would motivate community organizations, many of whom are juggling myriad programmatic priorities, to join a Unite Us network? The experience of a consortium of local food-focused nonprofits in the Bronx offers a few reasons. They teamed up with Unite Us and local hospitals to pilot and evaluate a referral network focused on addressing food insecurity.

First, the organizations learned a lot about their intended clients from the social needs screening questions that Unite Us includes in its platform. For example, they gleaned valuable demographic details, such as languages spoken, insurance status, and age to better tailor their services and outreach efforts.

The platform also helped participating nonprofits address unmet needs and expand their impact, both by offering their own services and referring people to additional services. For example, among clients that evaluators interviewed, only 6% reported using food pantries prior to completing the Unite Us social needs screening and referral process. Afterward, 56% reported using a pantry. The nonprofits also made a huge number of referrals to the Supplemental Nutrition Assistance Program (SNAP), a government program that was going underutilized. Of all the resource enrollments completed via the pilot, 58% were in SNAP.

Over the course of piloting the network, the organizations identified where their services were falling short and where more capacity was needed. For example, even among those already enrolled in SNAP or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), more than half of the people whose needs were screened reported being food insecure — a proportion that surprised the service providers.

Building a Case for Community Investment

That kind of capacity analysis is a big draw for health system partners too. They are eager, and in some cases also obligated, to make community investments, and they want to maximize their impact. “It’s incredibly exciting that we’ll be able, at a population level, to understand what the gaps are in the social sector. Then we can collectively figure out what the investment and advocacy strategies are to close those gaps,” said Loel Solomon, PhD, MPP, vice president of community health at Kaiser. “We don’t just see Unite Us as a care coordination and service delivery tool. It’s also a planning and strategy tool.”

Unite Us CEO Dan Brillman said he wants to do more than just bring together resources. “We are aiming to bring communities together, to align incentives and priorities, and then catalyze collective investment in those priorities,” Brillman said. “This is programmatic work. It is systemic work. This is not just about technology.”

In some communities, one of most impactful things Unite Us can do is shed light on the resource gaps that exist. For example, in that New York pilot, among respondents who had declined a food pantry referral, nearly a third said the available options were simply too far away.

Coming to California

Before launching a new community network, Unite Us works closely with local stakeholders to identify needs, priorities, and lessons learned from previous efforts. Although they follow a replicable process and use scalable technology, the networks Unite Us creates look different in each community — and Brillman and his team embrace that. “If this is not community-driven, it will not work,” said Brillman.

With support from CHCF, Unite Us has begun community meetings in Kern, San Joaquin, Merced, and Los Angeles Counties. The company is intentionally building on progress made by the 25 Whole Person Care pilots taking place under California’s Medicaid 1115 waiver, some of which have made significant strides toward breaking down silos between medical and social service providers. They are also working to align the major health care players, including Kaiser, CommonSpirit Health, and Blue Shield of California, operating in these communities to help maximize impact and minimize fragmentation.

“There’s no one organization that can solve these big problems like poverty on their own,” said Im of CommonSpirit Health. “We have to come together if we want to reach our ultimate goal — achieving equity and closing disparities.”

CHCF plans to fund an independent evaluation of the Unite Us approach, as well as some other research efforts to better analyze and standardize data collected by organizations working more broadly on the “social determinants of health.” Agreeing on a way to measure someone’s housing stability, for example, will make it easier to assess programs designed to improve that stability.

Although the early data on impact are limited, there is a sense of urgency among key health care players that the breadth and depth of social needs cannot wait for more data or more pilots.

“People are worrying about their next meal now,” Solomon said. “People are experiencing domestic violence now. These are needs people have now. This is urgent.”

If your organization wants to learn more about the Unite Us networks forming in California, complete this contact form.

Leslie Walker

Leslie Walker is a senior producer for Tradeoffs, a podcast exploring the confusing, costly, and often counterintuitive US health care system. She formerly served as communications consultant for the CHCF Innovation Fund. Prior to working with CHCF, Leslie led communications for the UCSF Bixby Center for Global Reproductive Health. Before that, she was a senior manager at SIRUM, a social enterprise start-up that connects organizations with surplus medications to patients in need. Earlier, she was a senior account executive at Fenton, a leading social-change communications firm, where she focused on media relations and message development for health care foundations and nonprofits. Read More

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