The American Journal of Accountable Care®
June 2018
Volume 6
Issue 2

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

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.

The American Journal of Accountable Care. 2018;6(2):e15-e17As the healthcare industry continues its transition from volume to value, it is critical for healthcare organizations to foster partnerships with community organizations to move the needle on health outcomes. The growing challenge of rising healthcare costs and poor health outcomes transcends industry lines. This means that the solution requires commitment and collaboration across sectors on all fronts.

Over a short period of time, the social determinants of health have emerged as a top priority at the federal, state, county, and city levels. We know that the structures that exist in people’s lives have an unparalleled impact on overall well-being and happiness. With this undeniable acknowledgment from all sectors, the conversations have changed. In the hospital setting, we are seeing providers seek ways to facilitate care outside of their specialty, whether by incorporating it into their practice, implementing screening tools, or generating external referrals. Within the payer world, we are seeing more investments in social programs and physical infrastructure, as well as the expansion of coverage to include behavioral health and social services.1

While this significant work is happening in healthcare, just as much innovation is occurring in the community. To date, a significant amount of funding and pressure has been directed toward the healthcare industry to solve the problem, but as many can guess, it will take more than just healthcare to solve this problem. It will take a village.

On the nonprofit and social service side, there are discussions around how to better support healthcare in the transition to value-based care. State programs have already started to integrate care between community-based organizations and health systems, and this integration is increasing dramatically.

A standard framework that has been consistent across organizations for expanding service delivery to incorporate social and behavioral services is to identify social needs through screenings, refer to external providers and partners, and track the total health journey of every patient in the community. This commentary will dive into this framework and discuss some partnerships rooted in the community that aim to support the transition from volume to value.

Identifying Social Needs

To develop systematic change within healthcare and social service delivery, there need to be tiers of service delivery that lead to a fully integrated system. With this shift toward delivering integrated care, there are 3 main categories through which healthcare organizations will navigate. Screening and identifying social needs is the first. With the implementation and successful adoption of accountable care organizations and other value-based initiatives, the use case for screening has been widely accepted. According to a Deloitte report, 88% of hospitals are screening for social needs as of April 2017.2 Although the report also noted that only 66% of these hospitals have implemented screening for social needs as a standard practice, their openness to adopting such screening is a huge indication that, more often than not, healthcare organizations are aware of, and engaging their high-utilization populations to identify, co-occurring medical, social, and behavioral needs.

As healthcare providers and care navigators screen for social needs, the next question becomes: How do we address these needs? Building community partnerships and programs is the path forward for many organizations, but the coordination and efficiency of this path is challenging. In an effort to identify resources and refer patients out of the clinical setting into the community, many entities have leveraged resource directories. These partnerships have helped move the industry forward to deliver care outside of the hospital’s 4 walls through community referrals, but unfortunately there have been some major challenges with this approach, including lack of visibility into the full patient journey, patients who are still seeking clinical care for their social needs, no information to track and measure outcomes and improved health, and limited accountability around the patients due to the lack of transparency.

To move the needle, healthcare organizations must invest in programs that support screening, referring, and measuring, not just 1 piece of this continuum.

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.

Related Videos
Related Content
CH LogoCenter for Biosimilars Logo