SDoH

You Asked, We Answered: Our Expert Team Shares Their Insight

By Ally Pratt on October, 23 2019
Team CHA-24-1

On October 1st, Unite Us co-hosted a webinar with Samaritan Health, one of our partners in Oregon, to discuss how we're helping them identify people’s needs, make referrals, and connect them to the care providers best suited to help. 

Participants had some terrific questions and there just wasn’t enough time to answer them all at once, so we thought we’d bring our team of experts together to weigh in and respond. Read on to hear what they have to say!

 

1. Part of the challenge of creating a CBO network to address social determinants of health is standardizing the manner in which social needs are evaluated, documented, and triaged prior to invoking a referral to the CBO. 
a. How do you address this in the platform?

Standardization is important. With more eyes turning to social drivers of health, translatable benchmarks are needed to clarify what’s really working (and where there’s room for improvement). It’s not just data; more people working together naturally standardizes language and other communication. Even at a granular level, when a clinical provider refers their patient to a CBO, the purpose and process should make sense to all three parties.

Good standardization is built from what’s already in place. Why do we need Unite Us? Organizations and services don’t need to be the same, but we need to be able to translate them. What value can we find in comparing transportation needs to food services? Co-occurring indicators.

You’ll see these practices in our platform. Highly configurable functionality – like programs, intakes, and outcomes – gives users flexibility to use something familiar. Yet, this configuration is built on pivotal keys to assist in translation. For example, I might record “Client Received Services” while your organization tracks “Enrolled In Program” – and each of these are categorized as a positive resolved outcome.

– Nick Cox, Product Manager

 

b. How do you address this in your implementation process?

At Unite Us, we’ve developed a phased rollout process to ensure network success. Each phase is designed with a goal in mind and builds upon the preceding segment. From a high level, these phases involve:

Discovery: We take the time to learn about you, your community, your partners, and more specifically, why you're interested in connecting health and social care.

Socialization: We work on the ground, hand in hand with your partners to create buy-in, develop workflows, and engage network partners.

Onboarding: We guide you and your partners through unique software configuration.

Training and Launch: We provide in-person training and support to prepare all participants for launch day.

Establishing quality, authentic relationships takes time. We could roll out a community network in one week, but our experience has shown that for true partner buy-in and the feeling of community ownership, there needs to be more of an evolution. This is a process, not a model. We've designed it to be flexible, with levers we can pull to adapt to a given community. No two communities are exactly the same, so we create a plan tailored to each of them.

– Brian Longo, Senior Enablement Manager

 

2. In a network, how do you approach coordination with multiple city and state agencies that provide social services? There is often another layer of privacy/data sharing concerns than with CBOs.

In a statewide coordinated care network, it’s important to have buy-in and strategic plans not only with state-level agencies (e.g. Department of Social Services, Department of Public Health, etc.) but also at the local level.

Working with local state agencies to understand the vision of a connected community while receiving state-level leadership support is essential to achieving adoption and true workflow integration. We host workflow planning as a part of our socialization process in order to coordinate with each of the local and state agencies. During those sessions, we review compliance, security assessments, workflows, and additional documentation needed to aid with the onboarding of the agency. Each local agency has their own process in which we customize our approach to help them onboard and feel comfortable with our data sharing practices.

– Megan Carlson, Community Engagement Manager

 

3. How does this get started in a community? Through a hospital, local government?

Unite Us networks can be spearheaded by not-for-profit organizations, hospitals or health systems, health plans, or government agencies. There is no right or wrong way to get started. We don’t always work top-down; we love to start at the grassroots level with community-based organizations, as well. Stakeholders in each of these groups have contracted with Unite Us – or otherwise partnered with Unite Us on an initial network buildout. More important than the organization that sparks a network is the implementation model we deploy to make sure that all of these kinds of organizations participate in coordinating care.

– Steve Strauss, Head of Network Development

4. Do you have any evidence of how community-based organizations might be using the referral and utilization data to obtain increased funding and resources to meet demand? It seems like there is a risk of increasing referrals without resources to handle increased demand.

Historically, community-based organizations have had to rely on public and private grants and donations to provide community members with critical services. As sectors such as healthcare recognize that CBOs are valuable partners in addressing social care, Unite Us offers opportunities to standardize data that will allow CBOs to measure the value of their services in order to get compensated fairly for their work. Unite Us data can be used to quantify and demonstrate these much needed services that CBOs are already providing.

Unite Us networks are participating in innovative value-based payment models where managed care organizations pay CBOs to address the social determinants of health. Our partners use our platform to connect community members to services and track referral activity and outcomes tied to payments. We believe the future of value-based payment is rooted in community-based organizations being paid equitably for the work they do, so they no longer have to chase dollars to keep their doors open.

– Michaela Ferrari, Community Engagement Manager

 

5. How does Unite Us help not only connect individuals to social/human services but allow those same organizations collaborating on longitudinal, relational engagement rather than transactional, episodic engagement to reduce narrowly focused cost of care outcomes?

Connecting humans to humans is at the core of everything we do. We’re breaking down silos between sectors and showing everyone that working together is more efficient and effective than working in isolation. For this work to be successful, we all have to be able to change our mindsets and imagine a new system that revolves around collaboration, partnerships, and information sharing to reach our common goal: helping people.

By onboarding, training, and engaging each partner in our networks and having them sign service level agreements, we’re ensuring that they are accountable to the network. This level of commitment means network partners are involved in their clients’ and patients’ health and wellness as a true partner, not just handing them a referral and sending them out the door.

Our comprehensive technology platform provides the visibility that network partners need for this to happen and our network-building process ensures it will. By generating meaningful data on services and outcomes, we empower our network partners to consistently improve the services they’re providing and optimize the way care is being delivered in their communities.

– Sabina Loscalzo, Director of Marketing

 

We were all impressed by the engagement and caliber of questions that came from this webinar. It’s exciting to see that our viewers truly understand the impact of our work and how we’re leading the industry. Community by community, we’re fostering meaningful cross-sector collaboration – supporting systemic change where it’s needed most.

 

Interested in learning more?

Contact Us

 

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