OPINION:
Rural communities have a historic opportunity to improve health care access, quality of care, and outcomes through the Rural Health Transformation Fund (RHTF), a novel funding stream dedicated to the much-needed transformation of rural America’s health systems.
In the coming months, the federal government will award these resources to programs that provide sustainable health care access, improve recruitment and retention of rural providers, and imagine innovative care solutions leveraging new technological solutions.
To accomplish those goals, states must solve for one of the most persistent challenges in health care: addressing the upstream factors that shape a person’s wellbeing long before they enter a clinic. As cofounder and CEO of Unite Us, I have seen how the economic and environmental pressures that influence health are routinely overlooked. Needs such as reliable food access, stable housing, and dependable transportation are often treated as separate from medical care, even though overall health outcomes and system efficiency improve when they are addressed together. When health care organizations confront these non-medical barriers alongside clinical services, rural communities see measurable gains and resources stretch further. That is exactly the vision underlying the RHTF.
States are envisioning comprehensive health solutions through RHTF funding. Indiana’s proposal seeks to implement a Food is Medicine model for procuring and distributing locally grown foods; Tennessee aims to invest in its rural non-emergency transportation program to support patients in accessing regular doctors’ appointments; New Mexico plans to support residents with down-payment assistance to increase access to housing.
These states have the right vision but executing on these plans requires the right digital infrastructure. At Unite Us, we support states in building seamless, data-driven solutions to support their transformative vision; we created our company to fulfill that exact need. Unite Us has worked with rural health systems across the country to identify gaps, recommend interventions, track real-time outcomes, and go the last mile in building bridges across sectors.
Unite Us partners with Missouri’s Transformation of Rural Community Health (ToRCH) program to strengthen partnerships between hospitals, primary care and behavioral health clinics, and community-based organizations (CBOs) that provide health and economic services like food assistance or housing — the pillars that support healthcare delivery.
Through ToRCH, organizations can seamlessly work together through the Community Information Exchange (CIE) software powered by Unite Us: a secure digital platform that manages patient eligibility for Medicaid benefits, enables all organizations to share resources, make referrals, track outcomes, and seamlessly facilitates reimbursements for CBOs.
The pilot began in 2023 with six hospitals in six different counties across rural Missouri. It has expanded to use Unite Us’ efficient payments solution, which seamlessly allocates Medicaid funding for essential services delivered to the community, enabling a more strategic and efficient approach.
In Virginia, Ballad Health collaborated with the Virginia Department of Health on a community health worker-led program to address non-medical needs using Unite Us’ closed-loop referral system. By collaborating across the Unite Virginia network which has connected over 66,000 Virginians to vital services since 2020 — Ballad Health was able to manage the full lifecycle of care from standardized screenings, identifying tailored resources, sending secure electronic referrals, and tracking outcomes.
The program saw a 16.2% reduction in overall emergency department utilization in the six months following a patient referral, a 24.8% average decrease in visits for patients engaged by Ballad Health community health workers in the six months following a referral, and $825,000 in estimated annual cost savings per 1,000 patients.
Much of our work began in North Carolina back in 2015 when we worked to build NCCARE360, North Carolina’s statewide care coordination network. Much like ToRCH in Missouri, NCCARE360 built new bridges between previously siloed stakeholders, shoring up systemic gaps and enabling easy follow-up for individuals and families seeking help.
Using NCCARE360, North Carolina launched the Healthy Opportunities Pilot (HOP) in 2022, was the nation’s first comprehensive program providing evidence-based interventions to high-needs Medicaid enrollees. The HOP program received significant attention, setting the standard of possibility for states looking to tackle health care costs at scale. Operating in largely rural counties, it provided assistance to over 40,000 residents in just three years, saving an average of $1,000 per member per year, based on a third-party evaluation. Unite Us’ platform enabled care managers to accurately evaluate individuals’ eligibility, resulting in a claims rejection rate below 5%, well below the typical rejection rates of 10-20%.
In rural communities, addressing non-medical needs is imperative if we are going to improve clinical outcomes and use resources efficiently. Digital tools allow stakeholders to take a holistic approach to care that, just decades ago, might have seemed unwieldy. When RHTF grants are awarded early next year, states should prioritize building data-driven systems that support this type of comprehensive approach. Rural communities may have specific needs, but they are solvable with technology that has already improved the health of communities across the country.
• Taylor Justice, an Army veteran, co-founded Unite Us in 2013 while enrolled at Columbia Business School, where he earned his MBA in 2014, and is now leading Unite Us on its mission to launch data-driven coordinated care networks nationwide. In 2020, Taylor was named to Crain’s New York Business’ “40 Under 40” list.
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