This document discusses the Healthy Together Referral Network, which aims to connect healthcare and social services through an outcome-focused referral network and software. It notes that currently, services are fragmented, with providers losing visibility after patient discharge and co-occurring health and social needs often going unaddressed. The referral network seeks to unite providers, track patient outcomes both within and outside of clinical settings, and drive better coordination through its technology platform and community engagement practices. The goal is to create a more accountable and coordinated system to address patients' health and social needs across regions.

1. Alliance
FOR BETTER HEALTH
+

2. Healthy Together
Ri,,ferral Ni,,twork of Alliance for Bi,,trer He th
THE PROBLEM
Service Providers are Fragmented
1. Healthcare and social service providers both lose
visibility after their patients are discharged.
2. Co-occurring health & social needs are often
under-addressed across the community
3. Vulnerable patients are seeking clinical care for
social problems
PROPRIETARY & CONFIDENTIAL
Community
Government
Healthcare

3. Healthy Together
Refe-rral Network of Alliance for Beue-r He-.alth
ltd UNITE us
80% of health happens
outside of your four walls
Coordinating with Community Based
Organizations (CBOs) is the solution to drive
outcomes
The key is ensuring CBOs are engaged and
integrated into your patients’ overall care
PROPRIETARY & CONFIDENTIAL

4. Healthy Together
Ri,,ferral Ni,,twork of Alliance for Bi,,trer He th
Inter-connecting healthcare & social services
into one accountable coordinated ecosystem.
Empowering health systems & communities
to work seamlessly together to impact every
person’s health and social needs.
HEALTHY TOGETHER REFFERRAL
NETWORK
Outcome Focused Network + Software Addressing the
Social Determinants of Health
PROPRIETARY & CONFIDENTIAL

5. Healthy Together Referral Network
Technology:
• Easy-to-use platform that tracks every step of the
patient health journey inside and outside hospital
walls.
Community Engagement:
• Community engagement practice and process.
Partnership between Unite Us and Alliance for
Better Health
PROPRIETARY & CONFIDENTIAL

6. Clowd CHes by Outcome for Employeflnent
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•--.. 1011...•- _..,l_ -
Closed Cases by Resolut>on ilnd Service Type
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Healthy Together
Refen-al Network of A ll.lance for Better He,
al1h
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lru UNITE US
OUTCOME FOCUSED APPROACH
COORDINATING ACROSS THE COMMUNITY AROUND EVERY PATIENT IN NEED
• Direct electronic referrals to best-fit provider(s)
• Track 100% of outcomes delivered by external partners
• Visibility into every patient’s total health journey
• Real-Time SDoH Outcomes & Performance Dashboard
PROPRIETARY & CONFIDENTIAL

7. = Dashboard Clients Reports My Networks Q I Sara Jones 9 I E] ® [+
X
Jane Smith i--F+i4UiiiB3Uh·F
AGE 35 I TEL 123-456-7890 I EMAIL jane.smith@email.com I ADDRESS 99 Main Street, New York, AK (
HOUSEHOLD 4 I HOUSEHOLD INCOME $32,000 I RACE Wh;te I ETHNICITY Non H;span;dLat;no
Records
SERVICE TYPE CR EATED"'
y Clothing Referral 8/31/2017
f: Employment
Assistance
8/23/2017
Request
Food Case 8/15/2017
'1' Legal Case 7/23/2017
= Benefits Referral 7/15/2017
Forms
NAME
NC Serves Clothing Assessment
NC Serves Employment Assessment
NC Serves Food Assessment
Intake 1
NC Serves Housing Assessment
NC Serves Employment Assessment
Healthy Together
Refen -al Network of All.lance for Better He,
al1h
Select
ASS I GNED TO STATUS
NC Serves Metrolina
D
Coordination Center
NC Serves Metrolina
D
Coordination Center
NC Food Bank • Iii
-
Housing Works • II
-
Single Shop • D
Select
UPDATE D
8/31/2017
Not Started
Not Started
7/25/2017
8/31/2017
Not Started
Timeline
JAN 1 6. 2018
9 Address Added by Ashl
;!I Employment Case Close
Resolution: Resolved
Outcome: Employed
Exit Date: 1/16/2018
Note: Client received
Representative at Tar
I Note Added to Employ
Interaction Type: Mee
Date: 1/16/2018
Duration: 1h
Note: Initial appointm
her resume. She will se
Employeement Referral
JAN 15. 2018
;!I Employment Case Creat
Organization: Employ
Description: Looking i
working part time.
;!I Employment Referral He
Reason: Scheduling an
AWP Clothing & Housing Goods
WHO REFERRED THIS CLIENT TO AWP?
WHEN WAS THIS CLIENT REFERRED TO AWP?
WHAT NEEDS DOES CLIENT PRESEl'IT?
Select all that apply
IS CLIENT INTERESTED IN A CLOTHING
HAS CLIENT SOUGHT CLOTHING SERVICES FROM ANY
ORGANIZATION IN THE COMMUNITY?
l(d UNITE US
FROM HELLO TO OUTCOME, YOU ARE CONNECTED
AUTOMATED WORKFLOWS BETWEEN EXTERNAL PARTNERS AT SCALE
Configurable Screening:
Patient and/or provider facing algorithmic screenings to stratify risk and
identify specific co-occurring needs
Electronic Referral Management:
Seamless referral workflow sends the right data to the right provider(s) to
address specific needs
Assessment/Care Plan Management:
Custom care plans for each service need that are attached to referrals so
receiving providers get a head start
Bi-Directional Communication/Alerts:
Automated notifications keep all organizations up to date, while care
team members can securely communicate with each other
Outcomes:
You get to know exactly what services were delivered, and the entire
history for every intervention by your external partners
PROPRIETARY & CONFIDENTIAL

8. HEALTHY TOGETHER REFERRAL NETWORK
INITIAL DATA AND FINDINGS
Efficiency has
increased by...
Average time
in days to..
4.69 52.09
1.78
5.04
...Intake and refer a client ...close a referral
■ APR ■ MAY ■ JUN ■ JUL ■ AUG
Healthy Together Mi UNITE US
Refen-al Network of A ll.lance for Better He,
al1h lW
PROPRIETARY & CONFIDENTIAL

9. Healthy Together
Refe.,ral Necwo,k of Alliance for Bene, Heal1h lru UNITE US
SUSTAINABILITY & SCALABILITY FOR THE LONG TERM
WHAT’S NEXT?
NYServes
Anti-Poverty Network
Hillside BHCC
AHI PPS
• Continue to grow & sustain Healthy Together Referral
Network
• Rollout internetwork referrals to neighboring networks
to ensure no person falls through the cracks
• Goal is to create an accountable coordinated ecosystem
of providers across regions, that are working together to
address the multiple and complex needs of our most
vulnerable populations. Healthy Together
Referral Network
PROPRIETARY & CONFIDENTIAL

10. Alliance
FOR BETTER HEALTH
ltd UNITE us
THANK YOU!
+
Taylor Justice
Keshana Owens-Cody
President
Director of Community Relations
taylor@uniteus.com
keshana.owenscody@abhealth.us