Ballad Health achieved an estimated $68.80 per member per month savings by using Unite Us’ closed-loop referral system to provide integrated care.

A newly released study analyzed the financial impacts and health outcomes that result when community health workers (CHWs) refer patients to services within their community using Unite Us’ closed-loop referral system. Connecting patients with support ranging from healthcare navigation to food assistance reduced emergency department (ED) visits by nearly 25% among patients with documented health-related social needs (HRSNs) or non-medical needs. This generated an estimated annualized cost savings of $825,600 per 1,000 patients—or $68.80 per member per month (PMPM).

The study was a collaboration among Ballad Health, the Virginia Hospital & Healthcare Association (VHHA), the Institute for Public Health Innovation (IPHI), and Unite Us, the nation's trusted technology partner for integrating health and community-based care. The patients were served within the Unite Virginia network.

“This study is yet another data point demonstrating that proactive, non-medical service coordination reduces overall costs while also improving patient outcomes,” said Halima Ahmadi-Montecalvo, vice president of research and evaluation at Unite Us. “A critical factor in the success of such efforts is a true closed-loop—having a way to ensure the patient receives what they need when they need it. Only then can it be effective.”

By facilitating the coordination and delivery of key health-related non-medical needs, such as benefits navigation, food assistance, or shelter, Unite Us helped reduce ED visits by 21 per 1,000 patients in clients served by Ballad Health in Southwest Virginia.

“This evaluation reinforces what we have long known—addressing non-medical drivers of health is not just the right thing to do, it’s a healthcare imperative,” said Paula Masters, chief health disparities officer at Ballad Health. “Unite Us’ closed-loop referral technology enables us to go far beyond making referrals—we can securely track whether services were delivered and measure the impact in real-time. That visibility is critical. It allows our teams to close the loop on care, target interventions more effectively, and ultimately improve outcomes while reducing unnecessary ED utilization. We’re not just coordinating services—we’re creating accountability, efficiency, and measurable change across our communities.”

Bridging Healthcare and Social Services for Whole-Person Care

Recognizing the need for stronger coordination between health and community care systems, the Virginia Department of Health (VDH), in collaboration with VHHA, and other statewide partners launched Unite Virginia—a coordinated, technology-driven referral network improving Virginians’ access to receive the right care at the right time. Since its inception in December 2020, Unite Virginia has facilitated connections for more than 66,000 individuals, with over 3,000 partner programs spanning all 133 Virginia localities.

“Bridging the gaps between health and community care is critical to ensuring health and safety for all Virginians,” said Reisa Sloce, district director for VDH’s LENOWISCO and Cumberland Plateau Health Districts. “Through use of this framework, many local partners have provided essential services to Virginians in need, which is helping to reimagine how whole-person care can be delivered across the Commonwealth.”

Impactful Outcomes Through Strategic Collaboration

This study analyzed data from January 2020 to September 2024, linking Ballad Health’s UB-04 institutional claims form and utilization data with standardized referral data from Unite Us. Of the 1,019 unique patients identified, 873 had six months of healthcare utilization data available both before and after receiving a referral. The results were compelling:

• 16.2% average decrease in ED visits for all tracked patients in the six months following a referral
• For patients who received a referral and were engaged by Ballad Health CHWs, average ED visits decreased by 24.8% in the following six months
• $825,000 in estimated annualized cost savings per 1,000 patients, or an estimated $68.80 PMPM savings, based on reduced ED utilization alone.

Scaling Success for a Healthier Virginia

The success of Unite Virginia highlights the power of collaboration in strengthening healthcare delivery. With a robust network of partners and data-driven insights, Unite Us helps health systems, payers, and policymakers make informed decisions about resource allocation and program investments.

“Taking a comprehensive, team approach to meeting patients’ needs is an effective strategy to help achieve improved health outcomes and avoid unnecessary medical costs,” said Sean T. Connaughton, CEO and President of Virginia Hospital & Healthcare Association. “Community Health Workers are essential members of the health delivery system who are well-positioned to refer patients to support services and help them navigate clinical journeys. The results of this case study—by showing how CHW involvement benefits patients while avoiding unnecessary emergency department visits—demonstrate the value of this team approach.”

As Virginia continues to advance its healthcare transformation efforts, these findings will serve as a model for other states looking to implement sustainable, impactful solutions for addressing high healthcare costs and patient outcomes.

All non-profit community-based organizations can use Unite Us’ platform free of charge. Contact us to learn more: uniteus.com/contact/.

About Unite Us

Unite Us is the nation’s premier technology provider for integrating health and community-based care. Our advanced product suite is used to proactively coordinate services using data-driven insights, streamline referral and case management, and facilitate eligibility assessments and reimbursements across government, healthcare, health plans, and community organizations. The first of its kind, our closed-loop referral system prioritizes privacy and dignity and has integrated data and analytics tools used to measure impact, optimize programs, and shape policy. With over 1.7M services, we host the nation’s largest network of community-based health and economic services dedicated to improving whole-person health. Learn more at UniteUs.com and LinkedIn.

About Ballad Health

Ballad Health is an integrated community health improvement organization serving 29 counties of the Appalachian Highlands in Northeast Tennessee, Southwest Virginia, Northwest North Carolina and Southeast Kentucky. Our system of 20 hospitals, post-acute care and behavioral health services, and a large multi-specialty group physician practice works closely with an active independent medical community and community stakeholders to improve the health and well-being of close to one million people. By leading in the adoption of value-based payments, addressing health-related social needs, funding clinical and health systems research and committing to long-term investments in strong children and families in our region, Ballad Health is striving to become a national model for rural health and healthcare. Learn more at www.BalladHealth.org.

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