Spotlight on collaboration to address social determinants of health
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Frequently Asked Questions
Can referrals only be sent from healthcare providers to CBOs, or are there other possible workflows (CBOs to CBOs, CBOs to healthcare providers)?
Yes, CBO providers will be able to do more than just accept referrals from healthcare providers. CBO partners will be able to send referrals to other network partners (CBOs or healthcare providers) to address clients’ needs.
Can this be used for those outside of the attribution of AHI?
Yes, any client can be referred through the network; you will not have to determine if the client is a Medicaid recipient, or if they are attributed to AHI or another PPS. AHI will be analyzing the network data to determine attribution on the backend.
How do you manage data integrity and make sure clients aren’t duplicated?
Every time a user enters a new client into Unite Us, he/she is required to enter the client’s first name, last name, and date of birth. The system then checks these data points against the entire Unite Us database to see if the new user already has a “face sheet” (client file) in the system. If an existing client with a similar name (the system checks for nicknames, misspellings, common variations of names) and same date of birth exists, the system will present the user with the existing client’s name, phone number, and address and ask if the user wants to “use this record.” After confirmation that the “new” client and the existing client match, the user can click “use this record” and move forward with their work within the existing client file. To ensure privacy of data, users will need to be serving the client (or about to do so) to view service-related history.
My staff already have to enter information into software platforms (e.g. HMIS, EHRs)— is there any way to mitigate this double entry? It seems like this might add work onto my staff’s plate.
Unite Us is built on APIs and therefore can integrate with other software platforms. A thorough assessment has to be done to determine if the other platform is open to this (not all platforms are), and if it makes sense in terms of workflow, cost, etc. In response to the work using the Unite Us platform might add, many of your staff members are likely already assisting clients with other services manually, and with current resources, it can be an extremely time-consuming and frustrating process (identifying other services, reaching out to other organizations, following up with clients or other organizations to learn what happened).
We work with many partner organizations who actually save significant time even though they use both platforms. Rather than spending time searching for programs that can help your clients, and making phones calls and sending emails to potential partners, your staff will be able to use Unite Us to create a referral in a few moments, and track what happens to the client simply by receiving email notifications and logging into the platform.
We recognize that it’s a struggle to search for the best program to serve your client, and to spend a lot of time looking for resources. Our goal is to help you spend less time on making referrals and more time on your day-to-day job, increase your impact on your clients, and be able to demonstrate the full spectrum of services you provide. Additionally, partner organizations will receive referrals with relevant data to the client’s need, which has saved significant time for staff as they don’t have to collect it again once the client arrives to be served.
Do I have to log into this system every day?
No, you do not have to log into Unite Us every day. The system will send email notifications whenever there is anything in the system you need to act upon or when updates are made to your client’s cases. Beyond responding to new referrals, updating case outcomes when services are no longer being provided, sending referrals for clients, and maintaining your organizational information, you can utilize the system as much or as little as you want.
Registering our organization and programs seems overwhelming if we have a lot of programs that might participate. Are we able to start with a small amount of our programs and build?
Yes, limiting the programs (and users) that you choose to start with at the network’s launch does not mean that you will not necessarily be able to expand those programs (and users) as the network grows.
What will it cost my organization?
Network partners are not being asked to pay to participate in the network. AHI has covered the cost for a two-year period and is already actively strategizing on how to keep the network funded and growing post-DSRIP.
Is this system secure/compliant?
The platform is HIPAA and FERPA compliant, including all administrative, technical, and physical safeguards required by law. Information is stored on leading Type II SAS Servers and is transferred securely through 256 bit encryptions via HIPAA-compliant cloud based servers. Before the initial referral is sent out for any client, his/her digital signature must be obtained to consent to share information with other network providers to receive services. The consent form informs the client that their information will be stored digitally in confidence following all federal, state, and local privacy laws. Both the technical compliance (i.e. encryption and safeguards) as well as the permission and consent process ensures that all providers in the network do not have to take on any additional work related to security or privacy of information.
I understand that referrals can be routed through a central “Coordination Center.” What is the purpose of this?
Routing referrals through the Coordination Center has two main benefits for a referral network: (1) when network providers make a referral for their clients, they don’t have to take the time to decide which network partner is the best-fit for their client, and (2) when a network partner rejects a referral (if the client is ineligible for services, or they don’t have the capacity to serve the client at the moment), it doesn’t fall on the initial (sending) provider to figure out a new network partner to send the client to. The sending provider will receive updates and notifications when the CC staff send their referral back out, and be able to track that patient’s progress. Alternatively, Unite Us has the ability to enable direct provider-to-provider referrals.
Who “owns” the data?
Data is owned by the providers and the network, not by Unite Us. As stated in the network licensing agreement: “Each service provider shall remain the owner of any data of all individuals or natural persons registered with a service provider as clients.”
How does the Coordination Center choose which network programs to refer clients to?
The Coordination Center reviews each referral to ensure clients are referred to programs to which they are eligible, and are easiest for them to reach geographically. They would also take into consideration the program’s capacity for new clients. If the programs are identical, the Coordination Center would choose the appropriate provider based on the consumer’s/referring provider’s preference.
Is there a way to indicate that someone hasn't responded to a referral to make sure that no client is slipping through the cracks?
Yes. The software provides automated reminders to notify the sender and receiver organization that action has not been taken, and both the sending provider and Coordination Center can see in the software that action has not yet been taken. Part of the role of a Coordination Center is to follow up with any providers that have left a referral pending after the accepted number of days. If a referral is pending due to staff turnover, the Coordination Center’s communication will prompt any necessary updates to the organization’s users in the software. Alternatively, if the organization doesn’t respond, or is unable to serve the client, the Coordination Center can re-route the referral to another provider.
Is there a supervisor alert when an organization receives a referral or accepts a referral?
Yes. There are several different roles you can assign to users at your organization to define access and permissions. One role is the Referral Admin, which can receive alerts for every referral that is sent to his/her organization (and can also decide which other user(s) to assign those cases to). Additionally, there is a long list of optional user notifications in Unite Us which are configurable at the user level. For example, users may opt to receive an email notification when a referral has been accepted by another organization, when a note has been added to a referral they’ve sent, or when they’ve had an incoming referral pending for three days with no action.
Would a new user at an organization be able to see the referrals/case progress made for clients that an inactive user at the same organization worked with?
Yes, if there is a staff change the new user would be able to access the same information about any clients served by the program(s) they work on (viewing permissions are based on program and user role). In order to receive notifications regarding the clients’ progress, the new user would need to be re-assigned as the Primary Worker for that client’s need (supervisors can easily pull a list of all open cases and sort by Primary Worker).
Is Unite Us currently used in other cities in New York State?
Yes, Unite Us currently powers a network in the Greater Capital Region, spearheaded by Alliance for Better Health, another Performing Provider System with a similar mission to AHI’s PPS. We also have a veterans-focused network, an anti-poverty network, and a behavioral health-focused network in Rochester, as well as a veterans-focused network and a Community Navigator initiative focused on serving justice-connected individuals in New York City.