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Robin Kish (Host): Communities nationwide have many social agencies that can help feed families and provide shelter. The key is linking services with the people who need them. One public health care system in Palm Beach County, Florida uses a community network to address social needs and improve lives. How connecting those in need to social services may be the best medicine on this edition of Here For Your Health. Welcome to the Healthcare District of Palm Beach County's podcast, Here For Your Health. I'm your host, Robin Kish. Our guest today is Corinna Kelley with Unite Us, a community referral network that is working with the Healthcare District of Palm Beach County and other social service agencies in an initiative called Unite Palm Beach County. Thanks for joining us Corinna.

Corinna Kelley, MPH (Guest): Hi. Thank you. It's a pleasure to be here. Thank you for having me.

Host: Sure. So, Corinna to stay healthy, we need many resources like nutritious food, medical care, and a safe place to live. Why are these examples of what are known as social determinants of health not accessible for so many who need them, despite programs that are already in place to help?

Corinna: That's a great question, Robin. This is really a result of the fragmented system that we're seeing, where health and healthcare and social care are not working together. The US traditional efforts to improve health outcomes were sole responsibility of our healthcare system. We now know that in order to improve health and achieve health equity, we must broaden our approaches and learn about the community organizations that are here to support patient needs and work together to ensure those resources are assessable.

Host: Corinna, how does Unite Us utilize technology to work in communities across the country and specifically in Palm Beach County, Florida with the Healthcare District?

Corinna: Great question again. So, at United Us, we are addressing the problem of this fragmented delivery system. We are a veteran-led technology company that focuses on building and maintaining accountable, coordinated care networks of health and human service providers that are addressing all social determinants of health and connecting people to the care that they need.

We are working with networks like the Unite Palm Beach County in 40 plus, and also in 40 plus states across the US approximately 1500 counties, unifying health and social care providers through our secure and HIPAA compliant platform, which allows service providers to collaborate and share data of individual needs while protecting their privacy. Our service providers on our platform can view a person's entire journey from the start to finish. They can track their own data and outcomes, identify service gaps and at risk populations, as well as most importantly, empowering members of their community to take ownership of their own health.

Host: That sounds great. So, maybe you can enlighten us on what Unite Palm Beach County is and how you're working with the Healthcare District.

Corinna: Absolutely. So, we partnered with Palm Beach County Healthcare District and launched our Unite Palm Beach County coordinated care network in September of 2020 to help connect the Healthcare District's patients to needed community resources. Through this partnership with the Healthcare District, the community-based organizations in this Palm Beach County area are free to join the network and will receive ongoing training, engagement, and network support to guide them through making a referral and tracking a client's journey and outcomes.

Some of the top needs that we are seeing in the Palm Beach County area, are mental and behavioral health, physical health, which includes counseling services, housing and shelter, individual and family support, as well as food assistance. We are in need of more network providers who can provide housing, food assistance, legal, and even employment services.

Through the past year, the Unite Palm Beach County Network has been able to connect numerous individuals to care. We've, 70% of our closed service episodes are closed as resolved. And 75% of the accepted referrals are accepted within four days or less. So, we're connecting clients to care within four days or less, which, which is amazing for the Palm Beach County Community.

Host: That's great. So, folks don't have to wait to get the services that they need. Corinna, can you walk me through the process? How does someone access the Unite Palm Beach County Network?

Corinna: Yeah. So at Unite Us, we have our approach, which we call as the no wrong door approach. So, no matter where a person first enters care, whether it's the Palm Beach County Healthcare District, or if it's a community-based organization, the agency will start a case within our platform and conduct a screening, identifying those needs that the member may have. After that service provider has received consent from the individual to make the referral, they can seamlessly create electronic referral to multiple community organizations on the platform offering a variety of service types. So, service providers are able to communicate amongst each other, once this referral is put in place.

And they can also communicate with that individual seeking services to let them know where their referral is at and if you know, and be able to track those outcomes. So, with every referral made within our platform, interactions and outcomes are tracked allowing the care team to make informed decisions on the next steps for that individual. They will also receive this real-time updates through the individual's journey.

Host: That sounds incredible. I mean, often those in need of social services, lack transportation, are not able to get time off of work or face other challenges that may prevent them from getting help at agencies where they're referred. What are the ways you follow up to make sure that the clients are receiving the services they need? You mentioned that there's a tracking process. And then how are you able to measure the outcomes?

Corinna: Yeah. So, unfortunately, many of us at Unite Us know all too well the underlying barriers to assessing services. Many of us who work from Unite Us actually came from community-based organizations ourselves and were service providers. So we can understand a lot of these barriers that are being proposed.

So, what we've done is in Unite Us is created a safety net with our network support team that watches the network activity and ensures clients receive services they need no matter the complexity of the case or the size of the network. This user support is engaged in viewing what's happening on the platform at all times. And reaching out to supporting staff members to be able to jump in and assist when needed to make sure that the client receives those services in a timely manner. This team reaches out to the Healthcare District, Palm Beach County, and also those community-based organizations that are on the network to inform them of what referrals need action, how to take action to ensure an individual gets services and then we provide one-on-one training opportunities to prevent the delays in the future. One thing that Unite Us has also done is partnered with Lyft to reduce that transportation barrier that we're seeing all too many times and improve the access to care and health, and social care. So, coordinators and service providers who use Unite Us to make electronic social care referrals can now order or schedule a Lyft ride on demand to help patients access the care that they need.

Host: Yeah, that must be extremely helpful. Especially recently, during the COVID-19 pandemic, when it comes to transportation.

Corinna: Absolutely.

Host: Corinna, you touched on this a little bit, but what are the benefits of this electronic approach when it comes to communicating with clients and then managing cases?

Corinna: That's another great question Robin and technology is really leading the future, whether we're ready for it or not. I actually heard a funny saying the other day that no one is more stubborn than an Android user who won't switch to Apple. I thought it was because I am that Android user that won't switch to Apple, you know? And I think we're all creatures of habit. We're so used to the way that we've been doing business for such a long time, which we've noticed is handing out pamphlets to patients, letting them know what services are, provided, really leaving it up to them to make that initial phone call and that connection with another service provider or we're used to doing emails and phone calls that are really hard to track.

And so, you know, Unite Us, we hear a lot of that resistance when it comes to service provider and making that change to using a technology for that case management. And so I believe that the benefits outweigh you know, being able to switch to technology, the electronical approach, we're able to do case management more efficiently, and we really take the burden off of the patient who's needing that service.

We're really putting that back on those service providers who can collaborate amongst each other, we can add input to individual cases, preventing duplication of effort. We're able to streamline workflows and reduce burden on care providers. And most importantly, like I said, preventing an individual from repeating their story to multiple service providers by using our electronical database.

Host: Yeah, so there's almost a, the insight is available at your fingertips as opposed to constantly trying to get information from the client. Right? And having them retell their story, like you said. This really surprised me, research shows the death rate for people in need of social services, like housing, healthy food, and a living wage is similar to that of lung cancer. So, connecting to social services may indeed be the best medicine. Right? What does research show about the effectiveness of community resource referral platforms like Unite Us?

Corinna: Yep. So, we have been featured in a few different researches and we are also currently growing our own evaluation of research team at Unite Us to be able to participate in our own research studies of how well we're meeting the needs of the community and our partners and stakeholders. So, many of the stakeholders have reached the consensus that addressing social determinants of health requires collaboration and integration among healthcare plans, healthcare systems and community-based organizations, but there are still some barriers and gaps in how to go about this, when health and social service sectors are working in silos. There is need for funding to purchase the right tools and that will provide security and privacy protection for data sharing and integration with electronic health records.

Our technology-based referral platform is equipped to be that solution. We have shown effectiveness through obtaining high trust certification, which is the leading and trusting information security framework for the healthcare industry. We also have ability to protect individual privacy by user permissions and levels of access that are available through our platform. Research has also shown that our referral platform has helped to support the cross sector data sharing, which is the first step in supporting the individual and improving their care and care coordination.

Host: Unite Palm Beach County launched in September of last year. What type of impact is it making here in Florida and elsewhere in the country, Corinna?

Corinna: Yeah, so we've had many successes in the network that we serve. Unite Palm Beach County is just one of those networks and we are growing in the Florida region to be able to tell, you know, a lot more of these stories. What I think is important to note, is that we have been thought leaders in advancing health equity, and ultimately empower networks and support them in identifying barriers to care, addressing those barriers and improving the health of all people by incorporating health condition, health considerations, into decision-making across the sectors and policy areas to achieve equitable health.

We just had a presentation yesterday on advancing health equity and how Unite Us has really been that thought leader in that and how we can support these communities. And so we have some focus groups that are looking into criminal justice reform. They're creating centralized infrastructures that coordinates care and supports diversion and reentry initiatives to break that cycle of mass incarceration that costs the government billions of dollars. We are also reducing racial disparities in maternal and early childhood health by partnering with states, health systems and local organizations to coordinate care that addresses the social determinants of health for pregnant women and mothers with young children. And one other area that we're working on is it is with supporting efforts at detection and early intervention of adverse childhood experiences and providing a platform for referrals and coordination of services and treatment.

Host: I should point out because you mentioned it a couple of times, according to the Centers for Disease Control and Prevention or CDC, health equity is when each person has the chance to reach his or her full health potential without facing obstacles from social position or other socially determined circumstances. And that includes equitable, fair access to healthcare professionals, healthy food, and a safe living environment. For someone listening now who wants to get involved in this network, either a social service agency, a caseworker, or an individual in need, what do you recommend they do?

Corinna: Yeah, so, so first thing I'd like to mention is that Unite Us is free for the community based organizations to join. So, we have numerous networks that are in 40 plus states and in 1500 counties for them to join. Our goal is to be in every community and every state. So community organizations looking to join can also visit our website at uniteus.com. They can view our events and attend an information session in their area. That also includes a demo of our platform. These sessions are held by our community engagement team members who live and work within the community of which they serve. So, they're very familiar with each community that they live in.

We also have videos and testimonials from partners on our website to give a little bit more perspective from the community-based organization standpoint and how Unite Us is impacting the work that they do. More specifically for our Unite Florida website, we have an embedded assistance request form for individuals in need to make a self-referral, which will be answered by our support team and sent to an organization within their county here in the state of Florida.

Host: Great. And you talked about all the different ways that Unite Palm Beach County and Unite Us is impacting those in need. Any success stories you want to share?

Corinna: One thing that we're really working on and what we've done in the past year was really looking at, you know, COVID 19 and the impact that, that it was having and trying to be able to reach out to organizations that were able to fill the need. What we saw when COVID-19 hit was a lot of housing needs, employment needs as well as food assistance. And so really, what we're doing is we've worked internally with some of our network supporting teams to identify which organizations that we need on board and really facilitating that, joining the network, what that looks like and what services they could provide. We're also, you know, informing the Healthcare District of those new community partners that are on board and what services they could assist their patients with. And I think this cross sectional, you know, approach to being able to address the needs and really understand what those needs are, I think that was, that's the biggest success that we've been able to do.

Host: Well, thank you Corinna for all of your time and this great information. If you'd like to learn more about Unite Us, please visit Florida.Uniteus.com. If you find this podcast helpful, please share it on your social channel and check out our full podcast library for topics of interest to you at healthcaredistrictpodcast.org. Let us know what you think. Your review helps us reach more people just like you.

Today's podcast is brought to you by the Healthcare District of Palm Beach County. The Healthcare District is a unique safety net healthcare system located in South Florida and provides county residents access to primary care, skilled nursing and hospital care, registered nurses in nearly all of the county's public schools and oversight of the county's trauma system, which includes operating two life-saving trauma Hawk, air ambulances. Learn more by visiting hcdpbc.org.