Military Appreciation Month is a time to reflect not only on the service of our nation’s Veterans, but on our collective responsibility to support them when they return home. 

At Community Hope, that responsibility is at the core of everything we do. For decades, we have been dedicated to helping individuals and families overcome mental illness, homelessness, and poverty—with a deep and unwavering commitment to Veterans. We believe that the words homeless and Veteran should never go together and our work is grounded in providing not just services, but stability, dignity, and hope.

What Are Common Veteran Challenges When Transitioning Out of Service?

The Veterans we serve often face complex and interconnected challenges. Many are navigating housing instability or homelessness, while also managing mental health conditions, including PTSD. Others encounter barriers to employment or experience a profound sense of isolation after transitioning out of military life. These challenges rarely exist in isolation, which is why our approach focuses on whole-person care—addressing both the clinical and non-clinical needs that are essential to long-term stability and well-being.

How is Community Hope Addressing Some of These Challenges?

To meet these needs, Community Hope has built a comprehensive continuum of care designed to support Veterans at every stage of their journey. Our Veterans housing programs provide safe, stable environments that serve as a foundation for rebuilding lives. Through supportive services, including case management, employment assistance, and skill building groups, we help vVeterans regain independence. Our rapid rehousing and homelessness prevention case management programs offer compassionate, individualized care, and our Case Managers ensure that each Veteran is connected to the right resources at the right time. Our SSG Fox Suicide Prevention Grant Program team is able to provide critical support, resource navigation, education, lethal means safety, and much more so that Veterans and their families don’t have to go it alone. 

As the needs of Veterans have evolved, so too have our programs—expanding to provide more integrated and responsive support.

How Do Cross-Sector Partnerships Improve Veteran Outcomes?

Central to this work is the understanding that no single organization can do it alone. Partnership is not just a strategy for Community Hope—it is a necessity. By working alongside the U.S. Department of Veterans Affairs, The NJ Department of Veterans Affairs, The NJ Department of Community Affairs, local housing authorities, healthcare providers, and corporate and philanthropic partners, we are able to extend our reach and strengthen our impact.

Utilizing Unite Us to receive closed-loop referrals also allows us to expand our reach, especially nationally. Unite Us also allows us to have a secure platform to communicate with referring entities and Veterans who refer themselves for services. Through Unite Us, we can also collaborate with referring entities in order to reach Veterans who may be hard to reach. These collaborations create a more seamless system of care, helping to ensure that Veterans do not fall through the cracks and can access the services they need more quickly and effectively.

Cross-sector collaboration also allows us to think beyond immediate needs and toward long-term solutions. 

By leveraging the strengths of our partners, we are better equipped to address the root causes of homelessness and mental health challenges among Veterans. This network of support enables us to deliver more coordinated, holistic care—ultimately leading to better outcomes for those we serve.

What’s Next for Advancing Veteran Care?

Looking ahead, we are inspired by the opportunity to expand our impact even further. We are committed to reaching more veterans, deepening our partnerships, and continuing to innovate in how we deliver care. As the landscape of veterans’ needs continues to change, we remain focused on developing solutions that not only respond to crises but help prevent them—empowering Veterans to build sustainable, independent futures.

What drives us most is the shared commitment we see across our community of partners and supporters. When organizations and individuals come together with a common purpose—to serve those who have served us—we create something far greater than any one effort alone. Partnerships amplify our ability to provide access, opportunity, and hope.

This Military Appreciation Month, we are reminded that honoring veterans goes beyond words. It requires action, compassion, and sustained commitment. At Community Hope, we are proud to stand beside Veterans every day—working to ensure that each individual has the opportunity to live with dignity, stability, and the hope they have earned through their service.

Meet the Authors

Peggy Banko, MBA
Chief Development Officer

Jennifer Stivers, MA, LCADC, CCS
Chief Programs Officer

Learn more at
https://www.communityhope-nj.org/

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Lebanon, New Hampshire – March 18, 2026 – Dartmouth Health and the New Hampshire Department of Health and Human Services (DHHS) today announced the recent launch of the Dartmouth Health Upper Valley Community Partner Pilot, a regional initiative of New Hampshire Care Connections. New Hampshire Care Connections strengthens coordination between healthcare providers, community-based organizations, and state partners to better support the health and well-being of Granite Staters.

The Dartmouth Health Upper Valley Community Partner Pilot was established with DHHS and Unite Us, the state’s technology partner for integrating health and community-based care. In collaboration with the Granite United Way, the Pilot is creating a regional network of health care and social service providers working together to improve how individuals and families access essential health and social services by creating a coordinated, secure referral system.

“Partnerships like the Dartmouth Health Upper Valley Community Partner Pilot are critical programs for us at Dartmouth Health in our ongoing work to improve health outcomes in the communities we serve,” said Joanne M. Conroy, MD, CEO and president of Dartmouth Health. “Gaps in communication between health and social service providers impact health and this can be improved by creating a system that links these entities together. I am proud that Dartmouth Health will play a role in the creation of such a system in the Upper Valley.”

New Hampshire Care Connections enables participating healthcare and community organizations to securely send and receive electronic referrals, track outcomes, and better understand community needs related to non-medical drivers of health, including housing stability, food access, transportation, and other critical supports. 

“We are proud to partner with Dartmouth Health and Unite Us on this innovative project to connect healthcare providers, community organizations and other stakeholders on the issues that matter most to the people of the Upper Valley,” said DHHS Commissioner Lori Weaver. “The launch of the Upper Valley Community Partner Pilot marks a major milestone in our work to establish New Hampshire Care Connections. We are excited to learn from this first phase as we build regional networks throughout New Hampshire to create a statewide coordinated referral system that will help everyone in New Hampshire access the services they need to thrive.”

The Pilot will serve as a real-world demonstration of how coordinated referrals between healthcare and community-based organizations – supported by shared technology, aligned workflows, and strong community partnerships – can improve care delivery and patient outcomes.

“At the heart of this effort is a strong collaboration with Dartmouth Health, the NH DHHS, and community organizations across the Upper Valley,” said Taylor Justice, co-founder and CEO of Unite Us. “This work is driven by the community itself and by a shared commitment to ensuring that when someone needs help, local partners are connected and ready to respond in a coordinated and meaningful way. This approach helps individuals and families across New Hampshire live healthier, more stable lives.”

The Pilot is already underway, with community engagement activities beginning in January 2026 and a phased roll out of the New Hampshire Care Connections platform in spring 2026. Lessons learned during the pilot will inform continued rollout of the platform in other regions across New Hampshire.

“The Upper Valley has a collaborative network of service providers that is envied by other regions of New Hampshire,” said Lynne Goodwin, MSW, Human Services Director for the City of Lebanon. “The effectiveness of that network is directly related to getting key providers at the table, strengthening our community connections, and developing successful methods of communication and coordination.

I’m optimistic that with the support of NH DHHS, and leadership from Dartmouth Health as an anchor organization, we can successfully implement a closed loop referral system that improves people’s experience with health care systems in the Upper Valley and leads to better health outcomes.”

New Hampshire Care Connections is a statewide network of healthcare providers, human services agencies, and community-based organizations working together to support individuals and families by connecting them to needed services in real time. The network streamlines referrals, protects individual privacy and consent, and supports effective follow-up to improve experiences navigating the healthcare system and advance better health outcomes.

To learn more about the New Hampshire Care Connections project, or join the network, visit https://www.dhhs.nh.gov/programs-services/nh-care-connections. 

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Every holiday season, we’re reminded of how much people rely on one another. A shared meal. A warm place to stay. A ride to a doctor’s appointment. These acts of connection—even small ones—can have a big impact. 

But offering support is one thing. Making sure that support actually reaches the person who needs it is another.

Across the country, organizations are stepping up to address needs like food assistance, housing support, and transportation that can have a significant influence on health outcomes. However, many of the tools designed to help often fall short. A referral is sent, but no one knows whether it was received or followed up on. A family reaches out to an organization for help, but never hears back. A provider offers resources to a patient, but has no insight into what happened next.

During a time of year defined by follow-through, generosity, and care, these gaps can feel even heavier.

That’s why this season, we’re celebrating what it truly means to close the loop. At Unite Us, our closed-loop referral system enables organizations to move beyond good intentions and deliver real outcomes that are powered by accountable networks, actionable outcomes data, and referrals that don’t sit on ice.

Because the best gift of all is knowing that support was not just offered—it was received.

What a “Closed-Loop Referral System” Really Means

As more organizations invest in solutions to coordinate SDOH referrals and connect people to essential support, the phrase “closed-loop referral” is becoming more common. But “closing the loop” is often interpreted differently, and in ways that don’t actually help organizations deliver meaningful impact.

Some platforms claim to support SDOH referrals, but in practice:

• Referrals are sent with no confirmation that they were received
• Clients are left to follow up on their own
• Organizations have no visibility into whether services were delivered
• Outcomes are reduced to vague categories like “got help” or “didn’t get help.”

A true closed-loop referral system works differently. It creates a comprehensive connection between the referring organization, the community-based organization (CBO) providing support, and the person receiving care. Organizations can see a comprehensive view of a client’s care journey, understand their longitudinal history, track services they’ve received, and monitor the outcomes of ongoing referrals. It provides clear updates at every step of the process and enables true collaboration rather than leaving referrals left on read.  

“What a Closed-Loop Referral Really Means”: 

Accountable Networks That Make an Impact 

Behind every successful closed-loop referral is a network of organizations committed to follow-through. However, many tools offer nothing more than a static resource directory—an outdated list of resources that may or may not be active, accurate, or responsive.

Accountability is what transforms a resource directory into a tool that actually works.

Unite Us partners with accountable, engaged, mission-driven CBOs that actively accept and complete referrals on the platform. These organizations aren’t simply names in a list; they are trusted partners who show up when individuals and families need them the most.

An accountable network enables:

• Stronger community relationships 
• Prompt referral acceptance
• Personalized support based on each person’s unique needs
• Confidence that referrals won’t “fall through the cracks”

During the holidays, when demand for food, housing, utilities, and transportation surges, an accountable community network that delivers real results becomes even more critical. 

“Other platforms don’t have the resources that Unite Us does. The difference in the organizations on the platform that actually interact and accept referrals is huge.”

– Bayhealth Read the case study

Actionable Outcomes Data That Shows What Really Happened with SDOH Referrals

Tracking outcomes is one of the biggest challenges for organizations addressing non-medical needs. Without clear data, it’s nearly impossible to know which services are making an impact, where gaps exist, or how to improve programs over time.

Unite Us’ closed-loop referral system is built to deliver actionable outcomes data that shows:

• Whether or not a referral was accepted 
• What services were actually delivered (e.g., food box delivered, stable housing secured, transportation provided)
• If necessary, what additional support is needed
• Patterns across communities that can guide investment and strategic planning

This level of visibility enables organizations to not just offer support, but to understand it and strengthen it.

During a season centered on generosity and connection, outcomes data like this becomes a powerful tool. It allows organizations to measure the real impact of their work, refine programs for the year ahead, and celebrate the meaningful change their teams and partners make every day.

Closing the Loop on What Matters Most

This holiday season, we’re celebrating the stories that show what happens when communities come together, and when technology strengthens human connection rather than replacing it.

“Closing the loop” means that:

• A family seeking utility assistance for their heating bill receives timely support
• A member recovering after a hospitalization receives medically-tailored meals 
• A patient is connected to transportation for their next doctor’s appointment 
• A veteran navigating housing challenges receives coordinated help rather than fragmented guidance

And for payers, providers, government agencies, and CBOs, it means having the confidence that every referral sent leads to measurable impact.

In a season defined by warmth, generosity, and community, closing the loop takes on deeper meaning. A true closed-loop referral system brings follow-through to the forefront, enabling organizations across sectors to give more, connect more, and create more meaningful impact—this season and beyond. 

Learn how our closed-loop referral system enables organizations to deliver real support and meaningful impact this holiday season.

Request a demo 

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Washington, D.C. — Nov. 3, 2025 — Lumeris, a leader in healthcare technology and services, today announced the formation of a coalition – Collaborative for Healthy Rural America (CHRA)™. Formed to help state leaders accelerate their efforts in the Rural Health Transformation Program (RHT) administered by Centers for Medicare & Medicaid Services (CMS) – the coalition includes Lumeris, Teladoc Health, Nuna, Deloitte*, and Unite Us.  

CHRA members will work together to deliver an AI-enabled interoperable operating platform that accelerates state RHT participants’ abilities to realize their visions. The platform will connect patients and clinicians—bringing national economies of scale to the local delivery of care in rural communities. 

“The Rural Health Transformation Program makes possible a new paradigm for healthcare access and delivery for millions of rural Americans,” said John Doerr, chairman of Kleiner Perkins. “We formed this collaborative to give states an immediate execution path towards their visions, with an AI-driven operating platform of class-leading technologies.”  

The need is urgent. Millions of Americans live in rural communities and many of them are covered by Medicaid and Medicare programs. According to the U.S. Health Resources and Services Administration, the nation faces a shortfall of more than 87,000 primary care physicians over the next decade, a gap especially acute in rural and underserved communities. 

The American Hospital Association reports that nearly 190 rural hospitals have closed since 2005 and more than 600 remain financially at risk. These challenges have left millions of Americans without consistent access to basic care. According to a study by the National Association of Community Health Centers and Health Landscape at the American Academy of Family Physicians, more than 100 million Americans lack access to primary care, and another 100 million receive care that is fragmented or suboptimal. 

CHRA aims to address these challenges through shared infrastructure, unified data, and modern technology. At the center is Primary Care as a Service (PCaaS)—a scalable platform to expand access, strengthen preventive care, improve chronic disease management, and coordinate care—while reducing administrative burden and stabilizing rural healthcare.

National scale, delivered locally

CHRA will adapt to the needs of each state while delivering benefits of scale—creating a flywheel of rising quality and lower costs. 

“CHRA was founded to leverage the government’s catalytic Rural Health Transformation investment as seed capital for a strategic, private-sector–funded solution to rural healthcare,” added Mike Long, chief executive officer, Lumeris, a CHRA founding member. “We fully support RHT’s goal to build a sustainable rural healthcare delivery ecosystem for future generations—one that ultimately lifts the burden on strained state and federal budgets.”

“The mission of CHRA aligns with Google Cloud’s efforts to help healthcare organizations improve operations and help clinicians provide better care, through the use of AI and cloud technologies. There is no better place to advance this work than underserved populations in rural America,” said Aashima Gupta, global director of healthcare strategy and solutions, Google Cloud. 

Guiding Principles of the Collaborative

• Provide comprehensive, scalable, technology-driven healthcare solutions to serve rural Americans
• Share benefits of national economies of scale to serve rural community needs
• Track sustainability metrics such as reduced preventable hospitalizations, higher patient satisfaction, higher patient self-sufficiency, stabilized provider finances and reduced administrative burden 
• Offer increased access nationwide within six months, and enhanced capabilities within 18 months, recognizing this goal may be limited by data access approvals and available infrastructure 
• Fully leverage and extend the capabilities of local care delivery resources

Founding Organizations and Roles

• Lumeris — Primary Care as a Service Platform. Through its AI-enabled Tom™ platform, Lumeris provides the backbone technology, workflows, and population-health visibility that make primary care function as a utility for rural America. Google Cloud’s AI models and infrastructure power AI-enabled Tom™ to bring together the best of AI, cloud computing, primary care expertise and proven solutions to help solve one of healthcare’s most intractable problems.
• Teladoc Health — High Quality Virtual Care Delivery. With the largest nationwide network of virtual care providers including licensed clinicians, therapists and health coaches, Teladoc Health delivers and orchestrates primary care, 24/7 urgent care, mental health, and chronic care services to expand access and improve outcomes in rural communities.
• Nuna —Daily Virtual Coach for Chronic Disease: Nuna’s platform includes an AI-native mobile app, a daily ‘coach’, to support patients to follow their physicians’ care plans. Nuna’s app notifies clinical care teams for support or intervention when necessary.
• Deloitte — Execution & Program Operations. Deloitte provides systems interoperability and data integration across IT platforms, using analytics and population data, to drive and measure program outcomes. Deloitte provides program execution and supports alignment of state efforts with the CMS Rural Health Transformation program guidelines.
• Unite Us — Human Services Coordination & Community Network Integration. Unite Us’ Self Sufficiency Score establishes a benchmark and measures the ongoing effectiveness of human service interventions, connecting rural residents to medical, behavioral, and community support services via an integrated care coordination and payment platform.

¹https://www.hrsa.gov/rural-health/about-us/what-is-rural

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NEW YORK – September 22, 2025 – CommunityCares is a collaborative effort between the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid agency; Contexture, the state’s largest health information exchange; and Unite Us, the nation’s trusted technology partner for integrating health and community-based care, has set a new standard for proactively addressing the non-medical needs that influence whole-person health. In just three years, the network has seen a remarkable 428% growth, demonstrating its effectiveness in connecting residents with vital community-based services across the state.

The success of the CommunityCares network is highlighted in a new short-form documentary that captures the program’s impact from the perspectives of some of its key partners. You can hear directly from community partners, AHCCCS, Contexture, and Unite Us on how this collaborative model has set a new standard for integrated care and is delivering measurable results for Arizonans.

Watch the full video on the Unite Us website to see how the CommunityCares network is transforming health outcomes and serving as a blueprint for other states.

Since its inception, the CommunityCares network has served more than 71K Arizonans and facilitated more than 185K referrals for vital health and non-medical services. This robust initiative, powered by Unite Us’ technology infrastructure, and Contexture’s expertise in secure information exchange, is transforming how residents access essential support, from housing and food security to employment and medical services.

Historically, Arizonans navigated a fragmented system when seeking assistance for basic needs. The CommunityCares network has transformed this by facilitating secure, closed-loop referrals through CommunityCares, built on Unite Us’ infrastructure. This system allows healthcare providers, government agencies, and community-based organizations to seamlessly assess an individual’s needs and connect them to available resources, delivering comprehensive, coordinated support. The network’s impressive growth includes onboarding over 1,400 organizations, creating a robust and interconnected care ecosystem throughout Arizona.

“Addressing social drivers of health is paramount to improving the long-term health outcomes of our members,” said Marcus Johnson, vice president of government affairs at AHCCCS. “The CommunityCares network has been instrumental in connecting our most vulnerable populations to the non-medical support they need—from housing to nutrition—to not just get by, but to truly thrive.”

Beyond streamlining referrals, CommunityCares gives care providers visibility into their clients’ care journeys, from the initial request to resolution. This outcome-driven approach not only improves individual well-being but also proves the financial sustainability and tangible return on investment of integrating non-medical services into the broader healthcare system.

The remarkable achievements of the CommunityCares network are a direct result of the strong partnerships at its core.

“The CommunityCares program’s success is a direct result of our powerful partnership with AHCCCS, Contexture, Unite Us, and community partners across the state,” said Brandon White, director of community and customer success at Unite Us. “Our technology turns this collaboration into tangible results, closing the loop on referrals and providing the data needed to prove the program’s impact, all while fundamentally improving health outcomes for Arizonans.”

“The success of the CommunityCares program is a testament to the dedication of every community-based organization and provider on the front lines,” said Melissa Kotrys, CEO of Contexture. “We’ve had the privilege of watching these partnerships flourish. We’ve proven that when you empower organizations with a seamless flow of information, they can deliver transformative, whole-person care. We are incredibly proud of what we’ve built and remain committed to fostering this ecosystem so we can continue to serve the people of Arizona for years to come.”

For more information about the CommunityCares network and its impact on community-based organizations, including how non-profit CBOs can join CommunityCares network free of charge, please visit contexture.org/communitycares/ or uniteus.com/networks/arizona/.

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NEW YORK – September 10, 2025 – Unite Us, the nation’s trusted technology partner integrating health and community-based care, has partnered with the Washington State Department of Corrections (DOC) to launch the Unite Us – Washington DOC Network, a new statewide integrated platform designed to support individuals reentering their communities after incarceration across Washington state. The network will connect people leaving incarceration to essential community resources, helping promote self-sufficiency and reduce recidivism, while strengthening public safety across Washington state.

Funded by the Smart Supervision Grant, this initiative will unify DOC divisions, community organizations, and individuals under supervision, streamlining access to reentry support.

Unite Us’ infrastructure serves as a critical tool to securely integrate service providers in real time across the Unite Us – Washington DOC Network: 

• Create a unified “one-stop shop” where both DOC staff and community members  have access to the same, consistent, and vetted resources—verified by Unite Us to provide reliable and up-to-date information.
• Facilitate seamless collaboration between divisions within DOC, enhancing continuity of care and fostering a shared commitment to positive outcomes.
• Continuously grow, offering an expanding continuum of services to proactively reduce barriers to successful reentry and further lower recidivism rates.
• Enable secure communication and closed-loop referrals with in-network community partners, streamlining service coordination.
• Deliver actionable, data-driven insights on program and service utilization, helping identify what resources are most effective and in demand.

“Our partnership with the Washington State Department of Corrections marks a significant step forward in building healthier, safer communities,” said Taylor Justice, president and co-founder at Unite Us. “By providing an integrated coordinated care network, we are not just offering a directory; we are creating a systemic approach to support individuals during a critical transition period, fostering greater success and reducing barriers to long-term stability.”

This initiative underscores the Washington State DOC’s commitment to innovation and collaboration in its mission to promote positive change and enhance public safety.

Non-profit community-based organizations providing social services may access the Unite Us – Washington DOC Network at no cost. To learn more, visit uniteus.com/contact/.

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NEW YORK, August 6, 2025 — Deloitte and Unite Us have come together to create a strategic collaboration designed to revamp how communities support their most vulnerable constituents. By blending Deloitte’s powerful data analytics and program insights with Unite Us’ expansive real-time coordinated network of health and community organizations, the collaboration aims to proactively identify needs, seamlessly connect individuals to the right resources, and improve mission outcomes. This is especially important in light of new Medicaid community engagement requirements.

“This innovative collaboration with Unite Us has the potential to redefine care coordination, empower greater self-sufficiency, and strengthen community engagement,” said Lindsay Hough, Deloitte’s state, local and higher education sector leader. “Together, Deloitte and Unite Us can help more people get the support they need when and where they need it. By combining our two organizations’ strengths, we’re making it easier for communities to coordinate that last mile of care that connects people with the service providers they need to deliver real results that create a lasting, positive change.”

By joining forces, Deloitte and Unite Us are creating a powerful collaboration that combines innovative technology with a vast network of community providers. It brings together Deloitte’s innovative solutions, like PeoplePrismTM and GovConnectTM Community Resource Engine, with Unite Us’ extensive outcome-focused provider network and predictive, cross-sector coordination technology.

Whether helping families find stable housing, making it easier for veterans to access support, or streamlining care for those facing a mental health or substance use crisis, state and local agencies, healthcare organizations, and community organizations will be able to quickly identify gaps, connect people to the right services, and monitor progress in real time.

Deloitte’s solutions leverage hyper-local data to personalize referrals, connect residents to the right services, and track outcomes to inform smarter resource allocation. These precise capabilities are complemented by Unite Us’ Community Resource Data Infrastructure, which uses advanced technology to validate and update service information, and its predictive analytics solutions that anticipate needs and analyze trends so organizations can proactively allocate resources and support self-sufficiency. Together, these technologies empower governments and communities to make better decisions, respond proactively, and improve the well-being of those in need.

“Unite Us is redefining how healthcare, government, and community partners work together, moving beyond referrals to deliver measurable outcomes, proven ROI, and real pathways to self-sufficiency,” said Taylor Justice, Unite Us co-founder and president. “By teaming with Deloitte, we’re helping government leaders see what’s working, fix what’s not, and connect their communities proactively to life-changing services faster than ever. Together, we’re equipping decision-makers with the tools and insights to streamline fragmented systems and build a connected infrastructure where every person gets the help they need, when they need it most.”

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