Raleigh, NC —  April 14, 2026 — Unite Us, the nation’s trusted technology partner for integrating health and community-based care, and WakeMed Health & Hospitals, a nationally recognized 970-bed not-for-profit health care system founded and based in Raleigh, N.C., are proud to deepen their collaboration to advance the health system’s Your Whole Health initiative.

WakeMed’s Your Whole Health program, which focuses on identifying and addressing social drivers of health (SDOH) that have a significant impact on health outcomes, will leverage a broader suite of Unite Us technology to more systematically identify, coordinate, and address non-clinical factors alongside clinical care needs, ultimately strengthening its whole-person health support for patients across the care continuum.

“Your Whole Health is about looking not only at the care we provide from a medical perspective, but what is contributing to a patient’s overall health picture,” said Theresa Amerson, MD, chief medical officer of Population Health at WakeMed. “Integrated screening tools like those provided by Unite Us allow us to better understand how things like access to food, reliable transportation, and a safe place to live impact our patients’ lives—and streamline how we connect patients to trusted community-based resources.”

A Tiered Approach to Community-Based Care Support

WakeMed’s expanded use of Unite Us enables a tailored approach to patient support based on level of need:

• Public Resource Directory supports low-risk patient populations by allowing patients and community members to self-navigate to available local resources when needs arise. Care teams can gain deeper insights into community needs and better understand what types of services patients are searching for, view top-viewed and shared programs, and more.
• Screening Ingestion and Automated Resource Lists support rising-risk patients by translating existing SDOH screening data into personalized resource recommendations, delivered directly to the patient and their care team through After-Visit Summaries and Epic MyChart. Patients can then self-navigate to resources, or staff can choose to share a resource list or send a referral to community-based organizations (CBOs) who can help meet their needs. 
• Unite Us Navigator supports high-risk patients by enabling closed-loop referrals to community-based organizations directly within WakeMed’s Epic EHR system, creating a more seamless experience for care teams and improving visibility into referral outcomes.

“WakeMed continues to show what is possible when care teams are equipped with the right tools to look beyond clinical needs and take action,” said Taylor Justice, CEO and Co-Founder of Unite Us. “By building this work directly into everyday care delivery, they are making it easier to connect people to meaningful support, strengthening coordination across settings, and helping ensure no need goes unseen or unmet.”

Improving Whole-Person Care in North Carolina

A leader in whole-person care, WakeMed continues to enhance its strategy by enabling patients with self-service access to local community resources, streamlining SDOH screening with automated resource recommendations, and natively embedding coordinated referral workflows directly within WakeMed’s Epic EHR system, which complements its existing use of Unite Us’ Closed-Loop Referral System and integrated Payments functionality. Together, these tools support WakeMed’s mission to provide compassionate, coordinated care that improves the health and well-being of the communities it serves.

Since launching the Your Whole Health program in July 2022, WakeMed has screened more than 300,000 unique patients, identifying the social drivers that influence overall health and well-being, and connecting individuals to meaningful community-based support through informed patient evaluations and care plans. The newly implemented Unite Us capabilities will enhance the work of WakeMed staff, reducing the burden on care teams to manually search for resources and follow up on referrals while enabling more seamless coordination of care.

Together, these tools help WakeMed—a Unite Us customer since 2019—continue advancing its mission and vision to be the provider of choice and preferred partner for quality health care, community health and whole-person care. 

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Earlier this month at HIMSS, I had the opportunity to represent the Gravity Project at the HL7 International exhibit, presenting alongside Katie Keating, Vice President of Solutions Engineering, on the role shared data standards play in powering rural health transformation. 

From Activity to Impact: Shifting How We Think About SDOH Data

For the past decade, there’s been a meaningful shift in how we think about health. Community-based services that address social drivers of health (SDOH)— or the non-medical factors that impact our health like food access, housing support, transportation, and maternal health services—are no longer seen as adjacent to healthcare, but as essential components of it.

We’ve also worked with our customers to build a growing body of evidence showing that when these needs are addressed, we see real outcomes: reduced total cost of care, fewer ED visits, and improved clinical measures like A1C and blood pressure control.

But one of the biggest challenges has remained: proving ROI consistently and at scale.

Moving from activity tracking (“a referral was made”) to outcome attribution (“this intervention improved this person’s health and reduced cost”) requires more than programs and partnerships. It requires a shared language.

Why Data Standards Matter

That’s where SDOH data standards come in.

Standards-based infrastructure,  like the work advanced through the Gravity Project and enabled through HL7 FHIR, allows clinical providers, community-based organizations, payers, and states to speak the same language. It creates consistency in how we:

• Capture social risk and needs
• Send and receive referrals
• Document services delivered
• Track outcomes and close the loop

Without that shared foundation, even the most well-designed programs struggle to demonstrate impact in a way that is measurable, repeatable, and scalable.

What This Looks Like in Practice

We’re now seeing leading states operationalize data standardization in meaningful ways.

In North Carolina’s Healthy Opportunities Pilots (HOP), the state built a first-of-its-kind program to pay for evidence-based, non-medical services for Medicaid members. In its interim evaluation, the program demonstrated $85 PMPM savings for enrolled members.

That result didn’t happen by chance. It required the ability to connect data across many different stakeholders like managed care plans, clinically integrated networks, and community-based organizations, and to consistently track services delivered and outcomes. 

Similarly, Missouri’s Transformation of Rural Community Health (ToRCH) initiative is showing how a hospital-led, community-based model can improve care coordination while also reducing administrative burden. Connecting hospitals and community organizations through shared, standards-based infrastructure, show the program is enabling more timely follow-up, better visibility into services, and HEDIS gap closures. 

In both cases, standards-based infrastructure t makes it possible to link actions to outcomes, with proven results. 

Why Data Standards Matter for Rural Health

This conversation is especially timely as states begin preparing for the Rural Health Transformation Program (RHTP), a significant, time-bound federal investment aimed at strengthening rural health systems.

At its core, the opportunity is not just to fund new programs, but to build systems that are sustainable. 

That means:

• Supporting rural providers under financial strain
• Expanding workforce capacity, including community health workers and doulas
• Investing in infrastructure that connects clinical and community care
• Demonstrating measurable improvements in cost and outcomes

But across all of these priorities, one requirement stands out: the ability to measure impact.

And in rural communities, where care often involves a complex network of providers, community organizations, and support services, that measurement challenge is even more pronounced.

Bringing It Back to the Individual: A Maternal Health Impact Story

Maternal health is a key priority across many states’ RHTP strategy. During our session, we used this as a lens to illustrate why standards-based infrastructure is critical to achieving meaningful, measurable outcomes.

Pregnancy-related mortality is up to 50% higher for rural individuals compared to their urban counterparts, and in some analyses, rates are nearly twice as high in rural areas. We also see higher rates of severe maternal morbidity, infant mortality, and complications like preterm birth in rural communities.

At the same time, access to care is declining. Over two-thirds of rural counties lack hospital-based obstetric services, and many patients are traveling 30–50+ minutes to reach care, if it’s available at all.

Imagine a pregnant patient in a rural community. She may be enrolled in Medicaid and receiving clinical care from a provider located over an hour away, without access to transportation and fresh produce. So when states set goals like improving maternal health outcomes as part of their rural health strategies, this is the reality they need to help individuals overcome. 

States may employ strategies to meet the pregnant mom where she is – connecting her to a community health worker to navigate access to transportation and food, and a doula to provide important prenatal education, supportive services, and advocacy. These non-clinical supports might be approved to be reimbursed by Medicaid within their state. Meanwhile, her provider is documenting in an EHR, the birthing hospital is documenting in another system, and the CHW/doulas in a third system, or using spreadsheets. At the policy level, a state Medicaid analyst who has never met the member, is trying to answer a critical question:

What actually improved outcomes for this patient, and what should we scale in order to positively impact more pregnant individuals?

That’s where standards-based infrastructure becomes essential. By understanding the social risk data the individual was experiencing (LOINC, snomed), what referrals were sent and what supportive services the individual was able to access and what outcome occurred (FHIR), what billable services were provided and reimbursed (Z-codes, HCPCs codes, X12 EDI), and enabling all of these stakeholders to be able to support this pregnant individual on their journey to receiving care (FHIR APIs), the analysts at the policy level are able to understand how programs on the ground are running and whether those interventions are making the impact they need. Without a shared language across all of these actors, it’s incredibly difficult to connect interventions to outcomes. This is why the work the Gravity Project does to create shared language and exchange is fundamental for programs to be scalable, replicable, and sustainable.

The Path Forward: Leveraging Data Standards to Power Better Rural Health Outcomes

Rural health transformation isn’t just about funding or new programs. It’s about building the infrastructure to enable providers to coordinate care across the continuum through secure data exchange, speak the same language through shared terminology, and measure the impact of programs in order to ensure sustainability. Standards are the foundation of that work, turning fragmented data into coordinated systems, and uncovering insights on impact.

Thanks to the important work done by the Gravity Project, technology infrastructure can adopt these shared standards and leverage interoperable exchange through HL7 FHIR to connect clinical care, community services, and policy analysis. This is what makes it possible to measure, scale, and sustain interventions.

When everyone is speaking the same data language, we don’t just track one-off activities. We can see what works and expand it to improve care for more people in rural communities.

Learn more about partnering with Unite Us for rural health transformation

The post HIMSS 2026 Recap: How Data Standards Power Rural Health Transformation appeared first on uniteus.com.

The Impact of Whole-Person Care
Whole-person care is an approach to health care that looks beyond immediate medical needs to address the full spectrum of factors that impact a person’s life, including environmental, behavioral, and economic needs. This approach recognizes that access to essential resources such as stable housing, food, transportation, and other non-medical factors is critical to achieving positive health outcomes. By coordinating workflows across healthcare and community-based services, whole-person care helps treat individuals holistically.

Unite Us and HealthEdge®: A Partnership Driving Change for Whole-Person Care

HealthEdge® is a leading provider of care management solutions for payer and provider organizations. Both Unite Us and HealthEdge share a common vision: empowering whole-person care through collaboration, interoperability, and strong community partnerships.

Whole-person care requires visibility beyond clinical data alone. By integrating referrals to community-based services directly into healthcare workflows, organizations can move from fragmented care to coordinated action.

Jennie shared how HealthEdge’s Guiding Care® solution for care management supports this vision by equipping payers and providers with the tools to manage complex populations effectively—and how their integration with Unite Us strengthens that capability.

“This integration [with Unite Us] is crucial in connecting members to the right resources quickly and effectively.” — Jennie Giuliany, RN, Senior Director of Clinical Sales Solutions at HealthEdge®

The partnership is a representation of how shared priorities, such as improving the user experience for care managers and effectively connecting members to community resources, can create innovative solutions that keep individuals at the center of care.

The Importance of Data in Addressing Drivers of Health

Jennie highlighted the importance of data for organizations responsible for addressing drivers of health:

“Not only are we seeing the impact we deliver to our members, but through data, we’re now able to demonstrate measurable outcomes and quantifiable impact. So, I think the world is taking notice.”  — Jennie Giuliany, RN, Senior Director of Clinical Sales Solutions at HealthEdge®

This recognition, Jennie explained, is a driving factor behind much of the innovation being seen in partnerships like Unite Us and HealthEdge®. By leveraging data and technology, care teams can bridge gaps in access to community resources for patients and members in need.

FHIR Interoperability Standards: A Game Changer in Healthcare Data

Interoperability was another critical focus of the discussion. Jennie emphasized the role of FHIR (Fast Healthcare Interoperability Resources) in standardizing how systems communicate:

“Interoperability standards like FHIR are really going to change the game when it comes to making health care data useful. Instead of data sitting in silos, FHIR gives us a standard language so that different systems can actually talk to each other. And because FHIR supports real-time data exchange, it’s not just about sharing the information, it’s about acting on it quickly. When you can do that, you can improve coordination, close those gaps in care, and ultimately drive better outcomes for members.”  — Jennie Giuliany, RN, Senior Director of Clinical Sales Solutions at HealthEdge®

Embedding Care Coordination into Existing Workflows 

Technology only drives impact when it fits seamlessly into daily workflows.

One of the most powerful aspects of the Unite Us + HealthEdge® integration is that care coordination workflows are embedded directly within the Guiding Care solution:

“Unite Us is fully embedded within our platform. Care managers don’t have to jump between multiple systems. As soon as a need is identified, the system will guide the end user to Unite Us to find and connect the member with the right services. And because it’s all tied to the care plan, the entire care team can see what’s happening and coordinate seamlessly, reducing that barrier with different systems trying to connect to each other.” — Jennie Giuliany, RN, Senior Director of Clinical Sales Solutions at HealthEdge®

When referrals to community resources are integrated into the care plan, not treated as a separate process, coordination becomes proactive instead of reactive.

The Power of Partnership in Driving System-Level Change

Throughout the session, both Rachel and Jennie emphasized the power of collaboration in creating person-centered care and achieving meaningful results. 

“Every time we help a member access resources that improve their health, we’re doing more than solving a problem. It’s a ripple effect. It results in better outcomes for members, financial stability for health plans, and greater job satisfaction for care managers. When we connect people to what they need, everyone wins. And that’s the kind of impact that transforms health care.” — Jennie Giuliany, RN, Senior Director of Clinical Sales Solutions at HealthEdge®

Rachel echoed the importance of aligned partnerships that move beyond integration toward shared impact:

“It’s exciting to see partners like HealthEdge leading the charge in helping payers and providers deliver more connected, community-centered care.” — Rachel Eager, Technical Program Manager, Integration Partnerships at Unite Us 

By combining interoperable technology with a shared commitment to improving health outcomes, partnerships like this help build a more accountable and coordinated healthcare system.

Key Takeaways for Healthcare Leaders

There were several key takeaways from the discussion, including:

• Whole-person care requires integrated workflows.
  Embedding workflows that address non-medical drivers of health directly into clinical systems ensures that needs are identified, addressed, and measured in real time.

• Interoperability is essential to scale impact.
  Standards like FHIR enable scalable, secure, and actionable data exchange across healthcare and community ecosystems.

• Tracking outcomes across the care journey is critical.
  Measuring service-specific outcomes, such as whether a food box was received, helps organizations demonstrate value while improving whole-person care for members and patients.

• Strategic partnerships accelerate transformation.
  Technology alone isn’t enough. It takes aligned partners working toward shared goals to drive system-level change.

Healthcare is at a turning point. As payers and providers advance value-based care models, integrating non-medical and clinical data is no longer a differentiator: it’s foundational.

Partnerships like this demonstrate what’s possible when interoperability, embedded workflows, and shared purpose come together to power whole-person care.

Visit https://uniteus.com/ and https://healthedge.com/ to learn more and explore opportunities for collaboration in your own organization.

The post A FHIR-side Chat: How HealthEdge® and Unite Us Are Powering Whole-Person Care Through Seamless Integration appeared first on uniteus.com.

In this episode, Unite Us joins AHA to explore how healthcare organizations are reimagining interoperability to extend care beyond the clinical setting and into the community. By embedding resource and referral workflows directly into EHRs and care management systems, health systems can identify, respond to, and track non-medical needs directly within clinical workflows.

We’ll dive into how integrations like SMART on FHIR and scalable APIs help care teams coordinate services with community-based organizations, streamline workflows, and track outcomes in real time across systems. We’ll also explore the importance of building for privacy, flexibility, and long-term scalability, especially for organizations focused on value-based, whole-person care.

Whether you’re just starting to address drivers of health or looking to scale your impact, this conversation offers practical strategies to improve health outcomes across your patient population.

Listen to the Podcast

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HONOLULU, HI– September 29, 2025 – The Queen’s Health Systems announced a three-year contract with Unite Us, the nation’s trusted technology partner for integrating health and community-based care, to support Queen’s Social Determinants of Health (SDoH) initiative, focusing on expanding capabilities for universal screening, targeted interventions, and addressing needs across the community.

Through this agreement, The Queen’s Health Systems will utilize Unite Us’ closed-loop referral system to connect to a network of community-based organizations. This will facilitate comprehensive tracking of a patient’s whole-person care journey, from initial screening to service delivery and outcome measurement. The data and insights gained are intended to inform Queen’s population health strategies, allowing for more targeted interventions and resource allocation to address the most pressing health-related non-medical needs within the diverse communities they serve.

“At The Queen’s Health Systems, our mission is to provide quality health care to improve the well-being of Native Hawaiians and all of the people of Hawaiʻi,” said Dr. Whitney Limm, The Queen’s Health Systems Executive Vice President of Clinical Integration & Chief Physician Executive. “Selecting Unite Us expands this commitment through an innovative digital platform to efficiently identify and address patients’ needs by community resources, while tracking progress and outcomes to ensure high quality, coordinated care.”

The agreement will support The Queen’s Health Systems to implement standardized SDoH or non-medical screening across both inpatient and ambulatory care settings. A cornerstone of this initiative is the commitment to support any positive SDoH screening, and patients are meaningfully connected to appropriate resources through Unite Us’ bi-directional platform. This integrated approach aims to improve care coordination and efficiency, empowering care teams to more effectively intervene on the social factors that impact health outcomes.

The initial year of this three-year contract will focus on integrations such as SMART on FHIR, screening ingestion, and an automated resource list. These integrations will support interoperability with Queen’s existing electronic health record (EHR) system, Epic, providing clinicians and care coordinators with a native Epic experience. This enhanced integration will give Queen’s care teams access to referrals across various departments, offering an understanding of initiated, closed, or pending support. By streamlining workflows and providing readily accessible information, the agreement aims to focus on direct patient care.

“We are honored to work with The Queen’s Health Systems, a legacy-driven organization with such a profound commitment to its community’s health,” said Taylor Justice, President and Co-Founder of Unite Us. “Our platform is designed to bridge the gap between healthcare and community-based services, creating a cohesive ecosystem where individuals can access the full spectrum of support they need. By supporting Queens’ Epic system, we aim to streamline workflows and provide critical data insights that will allow Queen’s to deliver person-centered care and impactful change in the lives of their patients.”

For more information about the Unite Us and The Queen’s Health Systems contract and its impact on community-based organizations, including how non-profit CBOs can use Unite Us’ platform free of charge, please visit uniteus.com/contact/.

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