{"id":11835,"date":"2026-04-15T10:00:20","date_gmt":"2026-04-15T14:00:20","guid":{"rendered":"https:\/\/uniteustailstg.wpengine.com\/?p=11835"},"modified":"2026-06-12T11:24:28","modified_gmt":"2026-06-12T15:24:28","slug":"santa-fe-connect-a-new-blueprint-for-government-led-community-care","status":"publish","type":"post","link":"https:\/\/uniteus.com\/case-study\/santa-fe-connect-a-new-blueprint-for-government-led-community-care\/","title":{"rendered":"Santa Fe CONNECT: A New Blueprint for Government-Led Community Care"},"content":{"rendered":"<h4><span style=\"font-weight: 400;\">Santa Fe CONNECT demonstrates how a government-led, technology-enabled approach can transform fragmented social and healthcare services into a coordinated system of community care. By collaborating with local partners to train and embed navigators across clinics, public agencies, and community-based organizations\u2014and unifying them through a shared referral and care coordination platform powered by Unite Us\u2014Santa Fe CONNECT created a single, accountable record of care for individuals seeking health and community services.<\/span><\/h4>\n","protected":false},"excerpt":{"rendered":"<p>Santa Fe CONNECT demonstrates how a government-led, technology-enabled approach can transform fragmented social and healthcare services into a coordinated system of community care. By collaborating with local partners to train and embed navigators across clinics, public agencies, and community-based organizations\u2014and unifying them through a shared referral and care coordination platform powered by Unite Us\u2014Santa Fe&#8230;<\/p>\n","protected":false},"author":5,"featured_media":11904,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"categories":[108],"states":[64],"topic":[84,86,88],"industry":[97],"series_name":[],"class_list":["post-11835","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-study","states-utah","topic-data","topic-healthcare","topic-technology","industry-all"],"acf":{"layout":"report","gated_page":{"":null,"title":"","featured_image":null,"description":"","form_title":"Fill out the form to download the white paper.","code_editor":"","title_2":"","description_2":"","embeds":null,"display_cta_button":true,"button_text":"Download the White Paper"},"columns":null,"download_page":{"document":""},"reports_component":{"components":[{"acf_fc_layout":"buttons","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"action_buttons":[{"name":"Read the Case Study","style":"button-solid","link_type":"external","page_link":null,"link":"#background","icon":"down-caret","is_blank":false,"background_color":"","text_color":"","background_color_hover":"","text_color_hover":""}]},{"acf_fc_layout":"key_takeaways","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","menu_label":"","header":"<h2>Key Takeaways<\/h2>\r\n<h3>In this case study, you\u2019ll learn how:<\/h3>\r\n<ul>\r\n \t<li><span style=\"font-weight: 400;\">Government buy-in and leadership enables system-wide coordination<\/span><span style=\"font-weight: 400;\">\r\n<\/span><\/li>\r\n \t<li><span style=\"font-weight: 400;\">Technology unlocks efficiency and transparency<\/span><span style=\"font-weight: 400;\">\r\n<\/span><\/li>\r\n \t<li><span style=\"font-weight: 400;\">Addressing health and non-medical needs drives measurable ROI\r\n<\/span><\/li>\r\n<\/ul>\r\n&nbsp;","takeaways":null,"text":"<hr \/>\r\n\r\n<h3><\/h3>\r\n<h3>Key Results<\/h3>","tiles":[{"header":"$13.4M","text":"Estimated Healthcare Cost Savings"},{"header":"3,294","text":"Estimated Administrative Hours Saved"},{"header":"$19.7M","text":"Estimated Generated Household Value"}]},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":"<span style=\"color: #ffffff;\">.<\/span>\r\n<h2>The Background: What is Santa Fe CONNECT?<\/h2>\r\n<a href=\"https:\/\/santafenm.gov\/connect\"><span style=\"font-weight: 400;\">Santa Fe CONNECT<\/span><\/a><span style=\"font-weight: 400;\"> is a joint partnership between Santa Fe County and the City of Santa Fe. CONNECT serves as a countywide care coordination and navigation network of trained navigators embedded in clinics, city and county programs, and community-based organizations. Navigators serve as care coordinators across the community, working directly with individuals to identify needs, initiate referrals, track progress in real time, and ensure follow-up across organizations.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">Grounded in the <\/span><a href=\"https:\/\/www.cms.gov\/priorities\/innovation\/innovation-models\/ahcm\"><span style=\"font-weight: 400;\">Accountable Health Communities model<\/span><\/a><span style=\"font-weight: 400;\">, CONNECT addresses individuals\u2019 unmet health and social needs\u2014such as housing, food, income support, and access to public programs\u2014by closing the gap between healthcare and community services.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">By creating a shared system of care, CONNECT:<\/span>\r\n<ul>\r\n \t<li><span style=\"font-weight: 400;\">Improves individual and community health outcomes;<\/span><\/li>\r\n \t<li><span style=\"font-weight: 400;\">Enhances the quality and continuity of care; and\u00a0<\/span><\/li>\r\n \t<li><span style=\"font-weight: 400;\">Reduces avoidable healthcare utilization costs across the system. <\/span><\/li>\r\n<\/ul>\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h2>The Challenge: Fragmented Care, Missed Opportunities<\/h2>\r\n<span style=\"font-weight: 400;\">Prior to implementing Unite Us as the program\u2019s technology infrastructure, CONNECT partner organizations relied on outdated, manual processes to coordinate care. Partners typically communicated through phone calls, faxes, and paper-based referrals\u2014methods that were time-consuming, prone to error, and difficult to track. These inefficiencies often resulted in delayed care coordination, and a lack of real-time visibility into client progress across organizations. <\/span>\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h2>The Solution: One Connected Record of Care<\/h2>\r\n<span style=\"font-weight: 400;\">Recognizing the need for a more effective and accountable system, CONNECT integrated <\/span><a href=\"https:\/\/uniteus.com\/products\/closed-loop-referral-system\/\"><span style=\"font-weight: 400;\">Unite Us\u2019 platform<\/span><\/a> <span style=\"font-weight: 400;\">into its existing workflows in 2019, creating a <\/span><b>single, shared record of care across community programs. <\/b><span style=\"font-weight: 400;\">This transformation enabled real-time referral tracking, closed-loop communication, and shared accountability across the network.<\/span>"},{"acf_fc_layout":"blockquote","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","text":"<span style=\"font-weight: 400;\">\u201cWe can see that our clients connected to the people we sent them to\u2026 there\u2019s a level of accountability now that didn\u2019t used to be there.\u201d\u00a0<\/span>\r\n\r\n<span style=\"font-weight: 400;\"><strong>\u00a0\u2013 Janelle Bohannon, MA, LPCC<\/strong>, Outreach Services Program Manager, The Life Link<\/span>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":"<span style=\"color: #ffffff;\">.<\/span>\r\n<h2>The Impact: Measurable Results, Real Lives Changed<\/h2>\r\n<span style=\"font-weight: 400;\">Since utilizing Unite Us, Santa Fe CONNECT has delivered sustained, measurable impact:<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"1\"><b><img class=\"alignright wp-image-12197\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/02\/SF_LCCS-quote-v5.png\" alt=\"\" width=\"266\" height=\"375\" \/>17,500+ referrals<\/b><span style=\"font-weight: 400;\"> sent<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"1\"><b>13,092 individuals<\/b><span style=\"font-weight: 400;\"> served<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><span style=\"font-weight: 400;\"><span style=\"font-weight: 400;\"><span style=\"font-weight: 400;\"><span style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Top identified needs:\r\n<\/span><\/span><\/span><\/span><\/span><\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Housing &amp; Shelter (24%)<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Income Support (22%)<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Individual &amp; Family Support (21%)<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Food Assistance (8%)<\/span><\/li>\r\n \t<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Benefits Navigation (7%)<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<em>*Data as of November 2025<\/em>\r\n\r\n&nbsp;\r\n\r\n<img class=\"alignnone size-full wp-image-12212\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/04\/SF-workflow-v8.jpg\" alt=\"\" width=\"1400\" height=\"728\" \/>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":"<span style=\"color: #ffffff;\">.<\/span>\r\n<h3>Economic &amp; Operational Impact<\/h3>\r\n<span style=\"font-weight: 400;\">CONNECT has scaled to meet growing community needs, delivering outsized returns for individuals, providers, and taxpayers. To date, it is estimated that the program has saved up to <\/span><b>$13.4 million in total cost of care<\/b><span style=\"font-weight: 400;\">,\u00b9<\/span><span style=\"font-weight: 400;\"> improved efficiencies for frontline staff by generating <\/span><b>over 3,200 saved administrative hours<\/b><span style=\"font-weight: 400;\">, and generated an estimated <strong>$19.7<\/strong> <\/span><b>million in household income<\/b><span style=\"font-weight: 400;\"> by resolving unmet needs,\u00b2<\/span><span style=\"font-weight: 400;\"> the cost of which would otherwise have been borne by individuals and their households in Santa Fe.<\/span>\r\n\r\n<img class=\"wp-image-11966 alignleft\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/02\/revenue-blue-sf.png\" alt=\"\" width=\"70\" height=\"96\" \/>\r\n<span style=\"font-size: 24px;\"><strong>$13.4M Estimated Healthcare Cost Savings<\/strong>\r\n<\/span>\r\n\r\nBased on North Carolina\u2019s Healthy Opportunities Pilot (HOP) findings of $85 <span style=\"font-weight: 400;\">per member per month<\/span> savings, applied to individuals receiving care coordination through CONNECT.\r\n\r\n<img class=\"wp-image-9316 alignleft\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2025\/08\/5-3-1.png\" alt=\"\" width=\"70\" height=\"96\" \/>\r\n\r\n<span style=\"font-size: 24px;\"><strong>\r\n3,294 Admin Hours Saved<\/strong>\r\n<\/span>\r\n\r\nAverage 13 minute time savings for each referred case based on a matched longitudinal survey of Unite Us end users.\r\n<h3 dir=\"ltr\"><img class=\"wp-image-9315 alignleft\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2025\/08\/5-2-1.png\" alt=\"\" width=\"70\" height=\"96\" \/><\/h3>\r\n<span style=\"font-size: 24px;\"><strong>\r\n$19.7M Generated Household Value<\/strong>\r\n<\/span>\r\n\r\nEstimated value of resolved needs (i.e. food, housing, transportation services provided) offsetting household income available to meet basic needs and improve quality of life."},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","wysiwyg":"&nbsp;\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h3>The Power of the Network Effect<\/h3>\r\n<span style=\"font-weight: 400;\">The CONNECT network has expanded significantly, now connecting individuals who reside in Santa Fe to 79 organizations. As a direct result of this increased collaboration, most referrals are accepted within just 1.5 days, and there has been clear, consistent improvement in case resolution rates over time. From 2019 to 2025, the percentage of managed cases that were resolved rose from 72% to 90%. While the total number of managed cases varied year to year, the overall resolution rate consistently increased, with 2024 and 2025 having resolution rates of 90%.<\/span>\r\n\r\n<img class=\"aligncenter wp-image-12427 size-full\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/04\/santa-fe-OrgGrowth-ResolutionRate2.jpg\" alt=\"\" width=\"1920\" height=\"608\" \/>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","wysiwyg":"&nbsp;\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h3><img class=\"alignright wp-image-11957\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/02\/janelle-quote-v3.jpg\" alt=\"\" width=\"275\" height=\"415\" \/>CONNECT Hub - One Client\u2019s Path to Self-Sufficiency<\/h3>\r\n<span style=\"font-weight: 400;\">When Joe* first reached out for help, he was facing one of the most difficult moments of his life. After losing both his housing and job due to a medical condition, he found himself without a safe place to stay and unsure where to turn. Past experiences had left him distrustful of systems meant to support him.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">Joe\u2019s first point of contact was the CONNECT Hub. A Hub navigator met him with compassion and urgency, taking time to listen, build trust, and reassure him that he would not have to navigate his challenges alone. Recognizing his immediate need for safety, the navigator connected Joe to several organizations, including an emergency shelter\u2014where he found a warm bed, meals, and a stable place to rest and recover.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">Once Joe was safely housed, the CONNECT Hub navigator referred him to a partner organization who helped him access the medical care he had been unable to receive on his own. With proper treatment and medication, Joe\u2019s physical and emotional health improved, giving him the strength to begin thinking about long-term goals.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">As his stability increased, Joe continued working with CONNECT navigators across multiple partner organizations to pursue employment. With support in finding job resources, completing applications, and preparing for interviews, Joe soon secured a steady job aligned with his skills and regained financial independence.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">Today, Joe is living on his own in stable housing, supporting himself, and thriving. What began as a moment of crisis became a path to self-sufficiency, made possible through coordinated, compassionate support.<\/span>\r\n\r\n<i><span style=\"font-weight: 400;\">*Name changed to protect client identity.<\/span><\/i>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","wysiwyg":"&nbsp;\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h2><img class=\"alignright wp-image-11909\" src=\"https:\/\/uniteus.com\/wp-content\/uploads\/2026\/02\/santa-fe-inaction.png\" alt=\"\" width=\"351\" height=\"241\" \/>The Cost of Inaction and the Opportunity Ahead<\/h2>\r\n<span style=\"font-weight: 400;\">The CONNECT network has already shown what\u2019s possible\u2014connecting individuals to food, housing, and other supports that improve health and stability. Yet the opportunity to make an even greater impact is clear.<\/span>\r\n\r\n<span style=\"font-weight: 400;\">Today, one in seven individuals who reside in Santa Fe County\u2014approximately 21,000 people\u2014face food insecurity. If the CONNECT model reached every individual facing food insecurity in the county, it could not only reduce hunger but also realize an <\/span><b>estimated $38.5 million in healthcare savings tied directly to food insecurity.<\/b>\r\n\r\n<span style=\"font-weight: 400;\">The potential impact is even greater for Medicaid beneficiaries. More than one in four individuals who reside in Santa Fe County rely on Medicaid (28%). If all of those individuals had their non-medical needs met through CONNECT, the community could experience transformative change\u2014improved health outcomes, stronger families, and<\/span><b> up to $45.4 million in healthcare savings<\/b><span style=\"font-weight: 400;\">, based on results from similar large-scale initiatives in other states.<\/span>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","wysiwyg":"&nbsp;\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<h2>Lessons Learned: Recommendations for Other Government Agencies<\/h2>\r\n<span style=\"font-weight: 400;\">For other government organizations considering similar technology solutions, Santa Fe CONNECT recommends:<\/span>\r\n<ul>\r\n \t<li><b>Building a unified technology infrastructure to bring together municipalities and CBO partners in one platform with standardized workflows and training.<\/b><\/li>\r\n \t<li><b>Investing in upstream community-based interventions to scale programs that already show strong ROI in healthcare utilization savings and household income gains.<\/b><\/li>\r\n \t<li><b>Using real-time data to drive decisions and resource reallocation based on emerging needs and service gaps.<\/b><\/li>\r\n<\/ul>\r\n\r\n<hr \/>\r\n\r\n&nbsp;\r\n<div style=\"font-size: 12px; line-height: 1.4;\">\r\n<div style=\"margin: 0 0 4px 0;\"><em>\u00b9 Estimated savings was calculated by applying the $85 <span style=\"font-weight: 400;\">per member per month<\/span> savings found through the North Carolina Health Opportunity Pilot\r\n<\/em><\/div>\r\n<div style=\"margin: 0 0 4px 0;\"><em>\u00b2 To estimate saved household income, we attributed an estimated value for each resolved Unite Us case, based on publicly available information specific to the state of Utah when available. These values represent additional money available to meet household needs due to services rendered (e.g. $50 in food from a food pantry 2 x per month).<\/em><\/div>\r\n<\/div>"}]},"webinar_components":{"components":null,"speakers":{"speaker_heading":"Speakers","all_speakers":null},"organizations":{"organization_heading":"Organizations","all_organizations":null}}},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Santa Fe CONNECT: A New Blueprint for Government-Led Community Care<\/title>\n<meta name=\"description\" content=\"With Unite Us, Santa Fe CONNECT created a single, accountable record of care for individuals seeking services to address unmet health and social needs.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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