Currently Viewing:
The American Journal of Accountable Care June 2018
Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model
Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
Lessons Learned in Implementing Behavioral Screening and Intervention
Richard L. Brown, MD, MPH
Currently Reading
The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care
Taylor Justice, MBA, President of Unite Us
Effects of an Integrated Medication Therapy Management Program in a Pioneer ACO
William R. Doucette, PhD; Yiran Zhang, PhD, BSPharm; Jane F. Pendergast, PhD; and John Witt, BS
Are Medical Offices Ready for Value-Based Reimbursement? Staff Perceptions of a Workplace Climate for Value and Efficiency
Rodney K. McCurdy, PhD, and William E. Encinosa, PhD
Utilizing Community Resources, New Payment Models, Technology to Deliver Accountable Care
Laura Joszt, MA
Cost-Effectiveness of Pharmacist Postdischarge Follow-Up to Prevent Medication-Related Admissions
Brennan Spiegel, MD, MSHS; Rita Shane, PharmD; Katherine Palmer, PharmD; and Duong Donna Luong, PharmD

The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care

Taylor Justice, MBA, President of Unite Us
As the healthcare industry continues its transition from volume to value, it is critical for healthcare organizations to leverage existing community partnerships to improve outcomes. 
AmericaServes: A National Blueprint to Deliver Integrated Care

An example of a program that has already started to do this type of work, and is addressing the same problems that healthcare is trying to solve, is AmericaServes, led by the Institute for Veterans and Military Families at Syracuse University. AmericaServes is a “first of its kind, coordinated network of service providers who are self-organizing as a collective body—above and beyond their own unique organizational designs—to ensure unequaled access to the very best and most comprehensive network of services, resources, and care designed exclusively for service members, veterans, and their families found anywhere in America.”3

AmericaServes leverages a network model through collective impact to build relationships among providers in different communities. Most recently, the healthcare sector has sought to solve this problem by referring out to the community, but building coordinated networks is a critical component to success. The veteran population is the perfect petri dish of American society when it comes to socioeconomic status, gender, and location. The organizations participating in the AmericaServes networks are not just veteran-serving organizations, but the same organizations that serve all populations and, in particular, are the organizations that healthcare organizations are looking to partner with to address the social determinants of health in their community.

AmericaServes launched in 2013 with its first network in New York City, which was originally funded by philanthropy. Five years later, the NYServes network has locked in sustainable funding from New York City through the Department of Veterans’ Services.

As of 2018, AmericaServes has 16 additional networks, leveraging the same care coordination technology (Unite Us), which means that all these organizations are using the same terminology and measures. Additionally, AmericaServes has enabled a national network of health and social service providers to coordinate care across the country. Veterans are known to be a very transient population, resulting in barriers to accessing integrated and seamless care, which makes connecting different state service organizations together a necessity to ensure that veterans don’t fall through the cracks and receive the same level of service delivery regardless of where they are in the country. Because the AmericaServes networks leverage 1 technology platform, Unite Us, there is 1 master patient index, which enables referrals among cities and states.

As a whole, AmericaServes has seen the following results:3
  • 16 community networks
  • 12,800 unique clients
  • 24,500 unique service requests
  • 84% of clients with resolved outcomes.

Leveraging 2-1-1 Systems to Increase Impact

Another program that has seen tremendous success is the SD United network, which is led by 2-1-1 San Diego and powered by the Unite Us technology. SD United is one of 2-1-1 San Diego’s Community Information Exchanges, which aim to bridge the gap between community providers (health and social) by creating a single centralized ecosystem of high-quality health and social service providers to support collaboration and coordination and track every outcome that is occurring across the community.

What does this mean moving forward? Is it sustainable to continue to build individual programs that vary state by state or even city by city? Or is it time to start thinking about how to build these programs at scale and increase interoperability not only between health systems, but also among health and social service systems? AmericaServes is the first to build a national model to deliver 21st-century health and human services and has provided a blueprint for healthcare and other industry leaders to follow to serve their most vulnerable populations. Technologies like Unite Us are working with public, private, and nonprofit organizations to innovate and build technical infrastructure to support scalability and increased impact. The examples of AmericaServes and SD United prove that developing coordinated networks across communities through 1 technology platform can work and is scalable.

Author Affiliations: Taylor Justice is co-founder and president of Unite Us based in New York, NY, and a US Army veteran. He earned a BS from the United States Military Academy at West Point and an MBA from Columbia University.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content.

Send Correspondence to: Taylor Justice, MBA, Unite Us, 65 N Moore St, New York, NY 10013. Email:

1. Edwards E. Assessing changes to Medicaid managed care regulations: facilitating integration of physical and behavioral health care. The Commonwealth Fund website.​managed-care-behavioral-health. Published October 24, 2017. Accessed May 2, 2018.

2. Lee J, Korba C. Social determinants of health: how are hospitals and health systems investing in and addressing social needs? Deloitte website. Published 2017. Accessed May 2, 2018.

3. Institute for Veterans and Military Families, Syracuse University. 2018 transparency report: coordinating care. transforming communities. AmericaServes website. Published February 2018. Accessed May 2, 2018.
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up