Can you start by telling us a little bit about Española Pathways Shelter and your role there?

Española Pathways Shelter has been serving our community for about seven years. I’ve been with the organization since the beginning, helping provide overnight shelter services for both men and women experiencing homelessness.

In addition to the shelter, I oversee Eagle Village Recovery Housing, a transitional program for individuals coming out of treatment. Participants must have completed at least six months in a treatment facility, and they can stay with us for up to 18 months while receiving case management, supportive services, and connections to other local resources through Unite Us.

What are some of the unique strengths and challenges of serving a rural community like Española?

I’ll start with the strengths; one of our biggest strengths is our close-knit community. I was born and raised here, and people really look out for each other. There’s a strong sense of family and local support, which helps us work collaboratively with both clients and their loved ones.

But rural areas come with their challenges too, transportation being a big one. Resources are spread out, and while we do have public transit, it doesn’t always reach the outskirts of our county. Río Arriba County is one of the largest in New Mexico—roughly the size of Maine—so getting services to everyone can be difficult.

What are some of the biggest barriers to health and well-being your clients face, and how do you help address them?

Access to care can be tough in rural areas. It can take a long time to establish primary care or find a provider who’s accepting new patients. Again, transportation is a major hurdle, especially for the elderly or those who aren’t comfortable with technology.

At Pathways, we use Unite Us to help clients connect with other local organizations. The ability to make referrals and warm handoffs through the network helps us navigate some of these barriers, bridge care gaps, and help people get the support they need. 

Can you share a success story from your work using Unite Us?

Absolutely. A few months ago, I received a referral through Unite Us for a client who was relocating from Santa Fe to Española to be closer to family. Through that referral, I was able to  access information about his goals and previous services.

That made it easy to pick up right where the other provider left off. As soon as he arrived, I was able to connect him with local resources right away. It made the transition seamless for him and saved us both a lot of time and effort.

Since joining Unite Us, how has your approach to connecting clients to care changed?

I’ve been a navigator on Unite Us’ platform for almost seven years now, and I’ve seen firsthand how it’s evolved. It’s made collaboration much easier for our case managers and shelter staff.

Beyond the platform itself, monthly navigator meetings—hosted by Santa Fe County—give us the chance to connect with others across the region. We share challenges, success stories, and best practices, which strengthen our community as a whole. Unite Us has become a crucial tool for ensuring that even outlying rural areas have access to coordinated care.

What’s the value of being part of a broader care network for a rural organization?

It’s huge. Being connected through Unite Us means we can see who’s in our network and refer clients quickly for the services they need. In rural areas where people may only get to town once a week, that efficiency and immediate access to local resources really matters.

The platform also helps us stay connected with other providers, even when we can’t meet face-to-face. It gives rural organizations a broader reach and helps us better serve our clients.

What advice would you give to other rural providers who are considering joining Unite Us?

I’ve been out in the community banging the drum about how critical it would be to get us all connected on the Unite Us network. For rural communities, they’d instantly have a broader base of opportunities to provide access to resources for the clients that we serve. 

I tell them that it’s extremely user-friendly—and I say that as someone who’s not very tech-savvy at all! The tech support is amazing. Any issues or any questions I’ve ever had, I get resolved quickly. Even if technology isn’t your strong suit, you’ll always have help and guidance from Unite Us. It’s a platform built to make collaboration easier, not harder.

Finally, what gives you hope for the future of health and human services in rural New Mexico?

I’m hopeful about the growing use of technology and platforms like Unite Us that bring providers together in one cohesive network. As more providers and organizations join, our ability to serve clients efficiently will only continue to improve. 

The more connected we become, the better we can overcome the barriers that make rural care challenging. I truly believe this kind of collaboration will shape a stronger future for rural communities everywhere.

About Española Pathways Shelter:

Española Pathways Shelter provides shelter, recovery housing, and supportive services to individuals and families in northern New Mexico. Through their partnership with Unite Us, the organization offers an evidence-based approach, as well as a wrap-around supportive services model, that provides comprehensive care alongside shelter and vital links to more permanent housing and stability.

The post Power in Partnership: Strengthening Rural Housing Access with Española Pathways Shelter appeared first on uniteus.com.

Stark County, Ohio – November 6, 2025 – Stark County, Ohio is proud to announce its pivotal partnership with Unite Us, the nation’s trusted technology partner for integrating health and community-based care. This collaboration will implement Unite Us’ closed-loop referral system, empowering the county to create the ConnectWell CIE of East Central Ohio, a countywide Social Information Exchange Network (SIEN) administered by Goodwill Industries of Greater Cleveland and East Central Ohio. This program enhances access to medical and non-medical services for residents by enabling secure electronic referrals, bi-directional data sharing, and real-time analytics to unify care across Stark County.

Stark County has long faced challenges connecting its residents with health services and addressing underlying non-medical needs. Extensive community engagement methods identified key non-medical drivers of health—including access to healthcare, food security, housing stability, and transportation—that often act as barriers to overall well-being. Partners in the ConnectWell CIE, including local foundations, local government agencies, and health organizations, are committed to overcoming these barriers. Research from Ohio University indicates that removing barriers for 10% of Stark County residents who need mental health treatment, substance use treatment, housing, transportation, and nutrition support could generate over $19.3 million in healthcare savings in one year. 

“Challenges the community faces in accessing vital healthcare and non-medical services are complex, but our commitment to the residents is unwavering,” said Anju Mader, MD, Director of the ConnectWell CIE and Chief Health Integration Officer at Stark County Mental Health & Addiction Recovery. “Unite Us provides the essential infrastructure to connect our dedicated service providers, streamline referrals, and ensure that individuals receive the comprehensive support they need to thrive. This partnership is a testament to our collective vision for a healthier, more connected Stark County.”

 Implementing Unite Us’ platform empowers Stark County to:

• Increase Healthcare Access: Create a coordinated delivery system for healthcare and community services, making it easier for residents to access physical and mental health support.
• Facilitate Closed-Loop Referrals: Enable seamless transitions between care providers and community-based organizations, reducing errors and improving follow-up rates.
• Generate Comprehensive Data: Provide robust data for metrics, allowing for the identification of unmet needs, emerging trends, and the assessment of intervention efficacy. This data is crucial in informing future policy and resource allocation.
• Enhance Community Collaboration: Build a stronger “community of care” around individuals and families by connecting health, human, and community-based service providers.

“We are incredibly proud to partner with Stark County in their groundbreaking efforts to integrate medical, behavioral, and community care,” said Taylor Justice, CEO and Co-founder at Unite Us. “Our platform is designed to break down silos and create a unified ecosystem where every individual’s needs are met with dignity and efficiency. The projected return on investment demonstrates the transformative potential of a fully functioning SIEN for Stark County.”

All non-profit, community-based organizations providing services to individuals can access Unite Us’ platform free of charge. To learn more, visit uniteus.com/contact/.

The post Stark County Partners with Unite Us to Launch Countywide Information Exchange to Improve Health Outcomes appeared first on uniteus.com.

From undiagnosed mental health challenges and unmet social needs to high rates of suicide and PTSD, statistics tell a sobering story about the health and well-being of those who have served our nation. In this webinar, we’ll explore how various demographic factors, health behaviors, and unmet social needs affect the health and well-being of Veterans. We will also discuss how these underlying factors affect the stress and mental health of Veterans. This session will highlight the need for targeted interventions to support the diverse needs of Veterans and outline strategies for policymakers, providers, and community members to improve care for this at-risk group. Don’t miss this chance to engage in a vital conversation about opportunities to improve Veteran health, well-being, and quality of life.

Moderator:

Halima Ahmadi-Montecalvo, PhD, MPH, Vice President of Research and Evaluation, Unite Us

Speakers:

• Marguerite Daus, PHD, RN, Assistant Professor, Department of Medicine, University of Colorado Anschutz Medical Campus
• Kristen Vescera, PhD, MPH, MA, Worried About a Veteran (WAV) Communications Lead, Army Combat Veteran
• Lori Murphy, MSW, LISW-S, Veterans Health Administration Senior Innovation Fellow

The post Bridging the Gap: Addressing Unmet Needs to Improve Veteran Health and Well-Being appeared first on uniteus.com.

An estimated 1.2 million people could die from opioid overdoses by 2029. While considerable progress has been made at the federal, state and local levels to deploy evidence-based strategies to address the opioid epidemic, all of us have a role to play in ensuring equitable access to essential care, including services that address basic unmet social care needs.

Whether you are a healthcare provider, policymaker, researcher, or community advocate, this webinar will provide valuable knowledge and actionable insights to help understand and address the opioid crisis through the lens of social drivers of health (SDOH).

Moderator:

Halima Ahmadi-Montecalvo, PhD, MPH – AVP, Research and Evaluation, Unite Us

Panelist:

Allyse Hawkins, LPCC, LICDC, Vice President of Behavioral Health at Oriana House, Inc.
Termeh Feinberg, PhD, MPH, Adjunct Faculty, Yale University School of Public Health

The post Breaking Down Barriers to Opioid Recovery: The Role of Social Drivers of Health appeared first on uniteus.com.

How addressing social drivers of health (SDOH) improves health outcomes for those affected by opioid use disorder (OUD).

It is estimated that more than six million Americans ages 12 or older have an opioid use disorder (OUD) and that in 2023 there were more than 110,000 drug-involved overdose deaths. The opioid crisis is a multifaceted challenge that requires a comprehensive approach, integrating both medical and social support systems, to shape the recovery journey of affected individuals. To effectively combat OUD, interventions must target the underlying social drivers of health, as factors such as economic hardship, housing instability, and limited access to mental health services can exacerbate both the prevalence and severity of OUD.

Risk factors associated with opioid use, misuse, and overdose include:

• Younger age – Drug overdoses and poisonings are the third-leading cause of pediatric deaths in the U.S.
• History of adverse childhood experiences (ACEs) – Analysis of Behavioral Risk Factor Surveillance System (BRFSS) data found that individuals reporting three or more ACEs had increased odds of taking opioids more than prescribed or without a prescription.
• Polysubstance use – More than 90% of individuals with OUD used more than two other substances within the same year and the majority of OUD-related deaths involve multiple substances.
• Other untreated mental health issues – Individuals with mental health disorders (e.g. anxiety, depression, bipolar).

Strategies for Addressing the Opioid Epidemic

Considerable progress has been made at the federal, state, and local levels in deploying evidence-based strategies to address the opioid epidemic. These strategies include primary prevention (e.g., reducing clinically inappropriate prescribing), harm reduction (e.g., Narcan distribution), evidence-based treatment (e.g., buprenorphine access), and recovery support (e.g., via peer support services). Ensuring equitable access to these essential interventions will undoubtedly prevent overdoses and save lives. The Centers for Disease Control (CDC) identifies that clinicians, community leaders, education, criminal justice, social services, business, and government all have a role to play in increasing access and linkage to care.

The CDC also recommends that linkage to care is bundled with other services (e.g., housing support, transportation assistance) to alleviate common barriers to treatment success, as effectively addressing the opioid crisis requires acknowledging and addressing the social drivers of health (SDOH) that contribute to OUD. By focusing on these underlying community-level factors — such as economic stability, education, healthcare access, and social support systems — we can create more comprehensive and sustainable solutions for the prevention and treatment of OUD.

Social Care and Opioid Use Disorder: Insights from the Literature

SDOH refers to the social, economic, and environmental factors that influence an individual’s overall health and well-being. Health-related social needs (HRSN) are the specific, actionable needs an individual may have within the broader social drivers of health. In recent years, a growing number of studies have emphasized the value of addressing the social needs of individuals with substance use disorder (SUD), defined as the inability to control the use of legal or illegal substances (such as stimulants, opioids, alcohol, or medications). Given the high rates of morbidity and mortality among individuals with OUD, along with the common occurrence of multi-substance use in this population, it’s unsurprising that many of these studies focus on individuals affected by OUD.

• A 2023 evaluation of California’s Whole Person Care Pilot – designed to coordinate the health, behavioral, and social care needs of Medi-Cal beneficiaries – found that participants with SUD experienced fewer ED visits ($32 per beneficiary per year decrease) and fewer hospitalizations per 1,000 beneficiaries ($310 per beneficiary per year decrease). 
• A 2023 retrospective study to assess the impact of recovery housing for individuals with SUD found that providing housing helped reduce readmissions to inpatient substance use treatment and that housed individuals had reduced ED use and increased primary care use. 
• A 2021 study funded by the National Institute of Drug Abuse found that case management, including service linkage to address basic needs, reduced inpatient readmissions and ED visits among a sample of 400 adults with comorbid SUD (including OUD) 
• A 2020 study of a model that integrates maternity care, SUD treatment, and social service coordination for pregnant Medicaid beneficiaries with OUD found that participants experienced reductions in foster care placements, fewer reports of child maltreatment, and an increase in prenatal visits. 
• A 2023 qualitative study to explore the perspectives of community-based clinicians and staff highlighted the need for better bidirectional care coordination between healthcare and community settings to support individuals with OUD. Participants reiterated that medication was important, but solving unmet social needs associated with ongoing opioid use was equally important. One clinician offering wrap-around support service stated: “They don’t know that services like ours exist. They think, ‘I can get meds, but how is that gonna help me with a place to sleep? Help me get my food stamps?’”

The Data is Clear. But Are Individuals in Need Getting Connected to Vital Services?

Most adults with SUD (94.7%) report not seeking treatment because they perceive that they do not need it. However, of the more than two million people with an unmet need for treatment, nearly half report that they do not know how or where to get treatment. Additionally, disparities in access to evidence-based treatment exist across groups. Based on an analysis of 2021 Medicaid claims data, one in three Medicaid enrollees with OUD did not receive medication-assisted treatment. Black/African American individuals, youth ages 18 years and younger, and individuals with a disability were all less likely to receive treatment.

Interventions that identify patients with SUD, initiate treatment, and link patients to community-based organizations (CBOs) are increasingly common, however, a 2023 scoping review identified several barriers to intervention success, including difficulties with:

• Building partnerships between hospital and community-based SUD programs
• Managing logistics and communication between hospital and community treatment teams to coordinate follow-up care for patients

Care in the clinical setting alone is not sufficient to address prevention, treatment, and recovery. Individuals with substance use disorders need clear access to comprehensive services such as employment, childcare, and housing. Building a path to recovery requires shared infrastructure to support community participation, coordinate care across service areas, and identify and activate evidence-based programs that effectively address diverse needs.

Insights from a Cross-Sector Collaboration Platform

Unite Us is an integrated suite of social care solutions designed to streamline processes and foster collaboration across government, healthcare, health plans, and community organizations to address SDOH. Insights from the Unite Us platform demonstrate how community-based organizations across the nation are collaborating to fight the opioid epidemic.

Since 2018, care professionals (e.g., community health workers, care coordinators, social workers) have leveraged Unite Us to connect more than 11,000 individuals with services to support their SUD recovery journey (15,000+ substance use cases). The top service subtypes referred to included substance use treatment, substance use recovery support, substance use counseling, substance use assessment, and tobacco cessation.

Data shows that substance use needs often co-occur with other types of needs. For example, nearly 1 in 4 individuals with a substance use need also had a mental and behavioral health need, one in 5 had a housing and shelter need such as transitional or emergency housing, 10% needed food assistance, and 10% needed support with benefits navigation (e.g., applying to health insurance). Effectively addressing the opioid epidemic requires recognizing that individuals with opioid use disorder may have co-occurring unmet HSRN that impact their ability to connect with ongoing treatment.

We observed an overall need resolution rate of 59% for substance use assistance requests, with no difference in resolution by gender, age, or military affiliation. However, we did find that the presence of co-occurring need requests can significantly influence the likelihood of substance use need resolution. For instance, the co-occurring presence of requests related to housing or shelter, food, and utility assistance, reduced the likelihood of resolution by 18%, 51%, and 40%, respectively. Conversely, needs related to individual and family support, mental and behavioral health, and transportation increased the likelihood of resolution by 158%, 50%, and 57%, respectively.

Supporting Individuals with OUD: Where Do We Go from Here?

• Recognize that individuals with OUD may have co-occurring unmet health-related social needs that impact their ability to connect with affecting and ongoing treatment. When using validated tools to assess the presence of SUD, also consider assessing for unmet social needs (and vice versa).
• When designing and implementing interventions, consider the unique needs of specific populations, such as justice-involved individuals, pregnant and postpartum individuals, American Indians, and Alaska Natives. Include the voice of individuals with lived experience of substance use challenges to inform compassionate, practical, and responsive solutions to real-world barriers to recovery,
• Continue to deepen our understanding of how addressing social factors can improve outcomes for individuals with opioid use disorder (for example, how does access to stable transportation affect adherence to medication-assisted treatment? Or what combination of social services yields the best outcomes for individuals in OUD recovery?)

The post Integrating Social Care Delivery into the Opioid Epidemic Response appeared first on uniteus.com.

As the market leader in empowering care coordination, Unite Us has witnessed many of the challenges that individuals face when seeking services across siloed providers, as well as the difficulties that Part 2 providers manage when working to coordinate care with their partners. The final rule aims to address those challenges by aligning Part 2 with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), thereby facilitating integration of SUD treatment information with other health information. In this way, the final rule will help enhance providers’ ability to treat the whole person and improve health outcomes, while continuing to protect the privacy of those seeking care.

In a letter to the Office of Civil Rights on a proposed version of the rule, Unite Us wrote: “Individuals with SUDs deserve equal access to coordinated networks of care to improve their health and well-being. Integrated whole-person care, which is critical for an individual’s health and well-being, requires that providers be able to share clinical information about the client’s treatment and their healthcare condition.” You can read Unite Us’s full comment letter here.

Read the Comment Letter

The post Unite Us Applauds HHS for Advancing Care Coordination and Improving Outcomes for Individuals with Substance Use Disorders appeared first on uniteus.com.

Across the country, communities are facing significant challenges in meeting the growing needs for behavioral health care services. Healthcare and community-based organizations alike have seen that they cannot tackle this surge in demand alone.

In this webinar, discover the strategic and coordinated efforts that champion a comprehensive and proactive approach to mental wellness—leaving no individual or community behind.

You’ll learn: 

• The pivotal role of community-based organizations in enhancing mental health care delivery
• Strategies for seamless collaboration between healthcare organizations and local community partners

The post Improving Behavioral Health: A Community Effort Webinar appeared first on uniteus.com.

Growing up with the Kennedy last name, our guest today was no stranger to larger than life pressure and responsibility, and grief and addiction. Throughout his career, Patrick decided to use his famous moniker to highlight the changes that needed and still need to happen in healthcare in regards to mental health and addiction.

Welcome to this episode of What Unites Us, a podcast about building businesses meant to last. We aim to answer some of the toughest questions about branding, leadership, and success while talking to business trailblazers about their biggest lessons learned.

Today, we welcome Patrick Kennedy, politician and mental health and substance use advocate. Patrick talks to us about his start in politics, his familial background with addiction, and what he believes needs to change in substance use and mental health care.

In this episode, you will learn: 

• Patrick’s political origin story (2:14)
• Patrick’s background with mental health and addiction (6:14)
• What Patrick believes should change when treating addiction (11:52)
• A compromise between those who want to restrict information sharing and those who don’t (16:21)
• What could change if we treat the stigma behind mental illness and addiction (18:55)
• Patrick’s tips for those who want to use their voice for advocacy (23:55)
• What’s wrong with healthcare and how to fix it (27:25)

Connect with Patrick Kennedy: 

• Website
• Twitter

Want to learn more about Unite Us? Our newsletter comes out the first Wednesday of every month. It includes our latest happenings, network news, announcements, and ways to get involved with our movement to connect health and social care. Sign up here. Follow our show on Instagram, Twitter, and Facebook and share your thoughts with us by emailing podcast@uniteus.com. 

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Episode Credits:
Produced by Ginni Media and Unite Us
Original music by Starling Studios

Copyright ©UniteUs2023 all rights reserved
All opinions expressed by podcast guests are solely those of the guest and do not reflect the opinions of Unite Us.

The post A Greater Obligation to Do More: A Conversation with Patrick Kennedy, Congressman, Advocate, Author appeared first on uniteus.com.

Today, there is an increasing demand for behavioral health services across the country and growing recognition that a holistic approach is needed to integrate behavioral health services with health and community services. 

In this webinar, you’ll learn about:

• The evolving policy and regulatory landscape (recent proposed changes to 42 CFR part 2)
• Best practices for integrating behavioral health, health and community services, 
• New innovations to empower communities and individuals across the country.

The post The Evolving Behavioral Health Landscape appeared first on uniteus.com.