Ballad Health and STRONG Accountable Care Community partner with Unite Us to launch coordinated care network for the Appalachian Highlands

Ballad Health and the region’s STRONG Accountable Care Community (STRONG ACC) are unveiling a new partnership and coordinated care network that will enhance community members’ health and well-being – even outside of hospital walls.

At a news conference on Thursday, June 10, Ballad Health and the STRONG ACC announced their partnership with Unite Us, joining both the Unite Tennessee and Unite Virginia networks, serving partners in the Appalachian Highlands. Unite Us is a national technology company that builds coordinated care networks of health and social service providers that will connect people with unmet health and social service needs, such as housing, food, transportation and employment.

“Since the merger that formed Ballad Health, we have fully embraced the effort of becoming a true community health improvement organization – one that can make a meaningful and measurable generational improvement in health and well-being in our region,” said Anthony Keck, Ballad Health’s executive vice president of system innovation and chief population health officer.

“For Ballad Health to be successful – and for our region to thrive – we all have to reach beyond our four walls and build partnerships to harness the power of collective impact. When we are all rowing in the same direction, we will demonstrably improve the health of the region.”

In December 2020, Virginia Gov. Ralph Northam announced the formation of Unite Virginia, a $10 million effort to expand the Unite Us network across the Commonwealth. Unite Tennessee and Unite Virginia recognizes the unique two-state, one-region nature of the Appalachian Highlands, and it will be the first time the Unite Us Platform is utilized in Tennessee. Unite Us operates its networks in more than 40 states, including communities in Kansas, Minnesota, Missouri, Nebraska and a statewide network in North Carolina.

Within Ballad Health, Unite Tennessee and Unite Virginia will allow specially-trained staff, conducting health-related social needs screenings for gaps in care, such as food and housing insecurity, transportation challenges or other obstacles, to connect with community organizations committed to resolving those issues. The network, however, is not dependent on Ballad Health. Participating organizations will also be able to refer clients to each other – even if the people they’re referring aren’t Ballad Health patients.

The success of Unite Tennessee and Unite Virginia largely depends on the participation of community organizations throughout the region. The STRONG (Striving Toward Resilience and Opportunity for the Next Generation) ACC is composed of more than 300 community partners from local and regional businesses, community organizations, faith-based organizations, healthcare organizations, schools and more, working together to improve the overall health and well-being of the Appalachian Highlands. In 2020, the STRONG ACC identified the adoption of Unite Tennessee and Unite Virginia as one of its strategic priorities.

“Healthcare, education, economic success – they are all interrelated. And likewise, social challenges such as housing, transportation and economic stability are also barriers that impede access to healthcare and impact health outcomes,” said Dr. Karen Schetzina, a professor and clinical leader with ETSU Health and Chair of the STRONG ACC. “The conjoined efforts of the STRONG ACC, the Unite Us Platform and our regional community health partnerships are all intertwined and working hand in hand to get upstream of generational health issues and create a stronger, brighter future for our children and grandchildren.

“With a ‘no wrong door’ approach, the experiences and outcomes of individuals seeking services will improve. Individuals will be welcomed into a community of organizations, all working to support the whole person and their family – not simply the problem that immediately presents itself.”

Knowing someone has unmet needs is not enough. Knowing who can meet those needs, what barriers might be in the way of serving those needs and confirming those needs are actually resolved is very difficult in today’s fragmented healthcare and social support systems.

“We were looking at software packages for a little more than a year,” said Lisa Cofer, executive director of the United Way of Bristol, one of the member organizations of the STRONG ACC and a network partner with Unite Tennessee and Unite Virginia. “The new Unite Tennessee and Unite Virginia program is such a godsend; previously, there wasn’t a single location for people to call and get the resources and navigation they need. This is going to be life-changing for us and the community we serve.”

With the software now in place, when an individual is served by a Ballad Health team member or one of the Unite Tennessee and Unite Virginia network partners, their specific social needs will be noted in the system. If, after obtaining the community member’s permission, a referral for a social service is made, the organization receiving the referral will be notified, and that individual’s progress in receiving the service will be recorded. This allows for closed-loop communication, which currently does not exist across the many different organizations in the region.

The Unite Tennessee and Unite Virginia network not only provides an up-to-date database of community resources, but it also offers insightful data that will help all network partners identify future needs and opportunities to better serve the region’s needs.

“There’s a very progressive, forward-thinking movement happening with our health and social needs organizations in the Appalachian Highlands,” said Mark Cruise, the new director of the STRONG Accountable Care Community. “Our community health transformation initiatives are being developed in true guidance with what our community is telling us they need, so we can tailor these community-driven and community-derived processes.

“In conjunction with Ballad Health and other STRONG ACC members, we’re bringing care out into our community and better understanding how we can all work together to mobilize around health improvement, stronger education and more economic vitality.”

The system integrates with Ballad Health’s Epic electronic medical record system, as well as with other systems and platforms used by community-based providers across Northeast Tennessee and Southwest Virginia. In its first year of operation, Unite Tennessee and Unite Virginia will have 100 users from Ballad Health and will be able to accept an unlimited number of community organizations as network partners.

“We are thrilled to partner with Ballad Health and the region’s STRONG Accountable Care Community,” said Mallory Hill, Appalachian Region community engagement manager for Unite Us. “As a lifelong resident of this region, I’m excited that together, we’re building a robust network of service providers connected through Unite Us’ secure, accountable technology, to ensure the community has the tools and resources it needs. The future is bright in the Appalachian Highlands!”

Learn more about Unite Tennessee or Unite Virginia.

Learn more about the STRONG Accountable Care Community and their ‘No Wrong Door’ initiative.