- [Announcer] Production and distribution of City Club forums on ideastream are made possible by the generous support of PNC and the United Black Fund of Greater Cleveland Incorporated.

(upbeat casual music) - Hello and welcome to the City Club of Cleveland.

Where we are devoted to conversations of consequence that help democracy thrive.

I'm Dan Moulthrop, Chief Executive here and a proud member.

Today is May 7th.

You're with the Virtual City Club forum.

We're live from the studios of our public media partner 90.3 WCPN ideastream.

Big thanks to them.

Even before the effects of COVID-19 ravaged the nation healthcare providers and social service organizations were putting increased effort into addressing people's most basic needs.

Things like food insecurity, safe housing, childcare, counseling and transportation and employment.

This was due in part to increased awareness of the reality that community conditions and social needs.

What we often refer to as social determinants of health, play a huge role in a person's mental and physical health and their ability to recover from illness.

The City Club has convened several forums on these topics over the years.

And today we're pleased to focus on a new solution happening right here in Cleveland.

Both the Cleveland Clinic and the Metro Health System have partnered with Unite Us.

It's a technology company that connects healthcare and social care providers through a shared electronic resources referral platform.

And this partnership is called Unite Ohio.

It allows for electronic referrals to and between social service organizations to address a patient's social determinants of health and then actually track the outcomes.

So, today we're talking with the individuals leading the launch of Unite Ohio.

And how they think it will improve the health of Northeast Ohio's most vulnerable residents.

Joining us are Daniel Brillman, he's co-founder and CEO of Unite Us, Unite Us.

Also with us, Dr. Nazleen Bharmal.

She's the Associate Chief of Community Health and partnerships at Cleveland Clinic.

And for Metro Health, Sue Fuehrer.

She's President of the Institute for H.O.P.E, which stands for Health Opportunity Partnership and Empowerment.

That's with the Metro Health System.

As I said, if you have questions for our speakers about this.

About attacking the difficult thorny issue of social determines of health.

Please text your question to (330) 541-5794.

That's (330) 541-5794.

You can also tweet your questions @thecityclub and we'll work them into the program.

Dan Brillman, Dr.Nazleen Bharmal and Sue Fuehrer.

Welcome to the City Club of Cleveland.

It's great to see all of you.

- [Nazleen Thank you.

- [Daniel] Thanks for having us.

- It's great to have you.

Dan Brillman, I want to start with you and the kind of origin of the Unite Us story.

How did this get started?

- [Daniel] Yeah, thanks for having me.

This started, 2010 was when the problem started, that I acknowledged.

I'm an Air Force Reservist.

I'm still in the Air Force as a Pilot.

I've been there for about 14 years and I was in the middle of business school.

And veterans that I served with started calling me expecting that I could solve both their health and their social service issues.

I tried to help as much as I can.

And what that meant was I was calling organizations across the country where people were back in their home towns.

And I saw that it was very fragmented.

And they were giving me some handoffs or numbers for other agencies if they couldn't help them.

And I became so frustrated that I really wanted to solve this for the people I served with.

And the way we thought about the problem is that people have multiple needs throughout their lifetimes.

And there's lots of organizations that service those those needs.

But not everyone does every type of service.

So, that requires a lot of deep coordination.

And ultimately it was on the veteran and the people that I served with that had to navigate each little silo of healthcare, government and social services.

And so, our goal as a technology company was to bring those organizations together as a coordinated system, in what's called a network.

That effectively provides whole person care and services around that person.

So that they don't have to navigate themselves through all of these silos.

And ultimately that improves health and efficiently lowers costs across the board.

And so, we did that for about five years.

And it focused on veterans and military families.

And then quickly the social determinants of health became a very popular term in the industry.

And we became more population agnostic.

We wanted this to be more of an infrastructure for entire communities or states.

That allowed for the secure connectivity between all these organizations that do amazing great work.

But really needed that connection between each other and ensuring that the person got the service on the other end.

We operate now in 42 states We're over a 500 person company.

And ultimately we're extremely mission driven and we're really about the end goal.

Did that person get the help they needed?

And we're excited to be here and obviously working in Ohio as well with great partners that are on the call.

- How many different cities are you working in right now?

- [Daniel] Lots, so in the 42 states.

Most of the metro areas.

We've gone obviously very deep into rural areas as well.

And I think it's over a thousand counties.

We think about from a where services are?

How people access those services?

And so, across those 42 states.

It gets very deep into those communities.

So, it's really beyond the city limits.

It's really getting, you know.

Where are those services?

Where do people need help?

And that's it.

That's where we ensure our staff are on the ground working with those agencies to ensure that we have the supply to service the needs.

- Dan Brillman is the founder and CEO of Unite Us.

A key partner in the Unite Ohio effort that is being led locally by Dr. Nazleen Bharmal at the Cleveland Clinic and Sue Fuehrer at Metro Health Systems.

Dr. Bharmal, I wonder if you could talk a little bit about what a fundamental shift this is for hospital systems.

And your colleagues who deliver medical care to be focused in this way on social determinants of health.

- [Nazleen] Yeah, I want to say first of all, great to be here.

It's actually a very, very exciting time But it is a huge shift, just like you said, for an organization that is a large integrated healthcare system.

That's used to delivering complex medical care inside clinical walls.

To shift their thinking to be thinking about conditions that affect where people are born, live, play, work, worship, the social determinants.

And with that shift it comes the recognition that healthcare systems might not be the experts in this area.

And really do need to partner with organizations that have the expertise to meet the social needs of patients.

Which we know have a huge impact on their overall health.

In fact, play a significant role on their overall health.

So, in this effort for many hospitals to really create like the healthiest communities around them.

Involves like listening to their patients, responding to their needs.

Partnering with the experts and investing in communities.

We're so excited about United Us because we feel that that particular platform in collaboration with community based organizations and our healthcare colleagues like Metro.

Actually meets all of those areas to get us to have healthier communities.

- Dr. Bharmal, if I could interrupt for just a moment.

I think social determinants of health as a phrase has become shorthand for a lot of people who are in social services, who are in the world of healthcare and who kind of understand what that refers to.

But there's a number of listeners, I think, who don't actually fully get what we're talking about when we say that phrase, social determinants of health.

- [Nazleen] Yeah, social determinants of health are basically the community conditions where people live, work, play, worship.

They include things such as housing, employment, education, transportation, utilities, food.

And we know more and more that where you live has a greater impact on your health than your genetic code.

This idea that your zip code plays a larger role in your overall health than your genetic code.

So, it's often the root causes for Hoffman disease and it's impacted by things like economics and social and economic policies.

- Dr. Nazleen Bharmal is with the Cleveland Clinic.

Sue Fuehrer with the Metro Health System is with us as well.

Sue is President of the Institute for H.O.P.E.

And I've already forgotten exactly what H-O-P-E stands for.

I think the E is empowerment.

Sue, but they help us understand where Metro comes into all of this.

- [Sue] Sure, so you know.

Metro has been really healthcare system that has taken care of everybody in our community for nearly 200 years.

And we've had many, many programs for a long time that really have moved beyond the walls of the hospital to help everyone live their healthiest life.

And address some of these social needs that our patients have.

But a couple of years ago, Dr. Akron Boutros, the CEO.

Really decided that we were gonna move a little bit faster and really try to take the lead in this area.

And created the Institute for H.O.P.E., which stands for Health Opportunity Partnership and Empowerment.

- [Dan] Thank you.

- [Sue] And so, we've.

- No, go ahead.

Keep going, keep going.

Yeah, but thank you for filling in those blanks that I left before.

- [Sue] Yeah, so, you know.

We've been at it for a couple of years now.

And early on in our journey we recognize that as a community we had a lot to learn from our healthcare systems experience and electronic health records.

Where we have different ones and they don't talk.

And so, at the Institute for H.O.P.E.

we convened people in the community.

So, we actually brought in the healthcare systems, United Way, Center for Health Affairs.

Dr. Goleta, Case Western Reserve, Better Health Partnership.

And we started evaluating referral platforms recognizing that we had to be able to talk together and it had to be transparent.

And we had some criteria.

Mainly that it was free or low cost to all 501c3s and federally qualified healthcare centers.

That not only did the health systems talk to the CBOs, community based organizations.

But the community based organizations could refer to each other.

And we just had a great example with Seeds of Literacy where we had a listening session with Unite Us.

And they said, you know.

So often we have people that can't read but they have so many other social needs and we didn't know what to do.

And Unite Us is the perfect fit.

Because now we have an easy way to reach out to our partners that may have food needs and things like that.

So, through evaluation we picked Unite Us and we launched at Metro on September 22nd to 2020.

So, we've been at it just a little more than six months now.

- And what have you found in six months?

- [Sue] We have found that through screening 60% of the patients that we see have at least one social need.

And nearly 20% have three or more social needs.

So, there is a huge demand out there.

And through the Unite Us network we can create referrals for the social demands.

Such as food, transportation, housing, utilities, even digital connectivity.

And we can connect through a very meaningful way through private.

You know, that's private and HIPAA controlled.

We can connect that patient with a CBO.

And when that CBO- - [Dan] Community based organizations.

- [Sue] Community based organization responds to the healthcare system everybody can see.

So, you know, the reality is our patients go to Metro and the clinic and UH and even the VA and they use CBOs.

So, this is helping things be really efficient because if the Greater Cleveland Good Bank is gonna address a need for a patient.

The Hunger Network doesn't need to step in.

The Euclid Food Pantry doesn't need to step in.

So, it's really making it effective.

What we hope to see, you know, as we grow is that clinical care teams will be able to see what has been done.

So, when the patient comes back.

You know, they'll say, oh.

We see you got utility.

So, you now have a refrigerator and I can safely prescribe insulin for you.

And I know that you're going to be able to take that insulin.

You know, and the goal will be hopefully will reduce some of the frustration that our clinicians see.

Because so much depends outside the medical facilities.

You know, doctors and nurses need help.

And Unite Us network is going to help us do that.

- Dan Brillman, could you share some of the success stories from other cities where this has been in place for a while.

And how that's transformed the patient experience.

- [Daniel] Sure, yeah.

And that's great that you said that.

The patient experience is of the utmost importance because ultimately it's about them and improving their health and the ways in which we do that.

But ultimately the patient now doesn't have to navigate through all the different silos that existed before.

They had to navigate themselves to food organizations and to the medical world and to the government services for benefits.

And so, no longer do they have to do that.

Everyone in this network is an access point.

So, if they show up to any organization or they reach out into the network anywhere.

Everyone has the connectivity to each other.

So, that's really important.

They only have to tell their story once.

And ideally- - [Dan] Wait, wait, wait.

- [Daniel] It's not just to the doctor.

- Wait, they only have to tell their story once.

'Cause I mean like every.

I mean not only when you're entering healthcare not only are you sharing your birthday every 10 minutes with somebody to ensure that you're the right person.

But typically what happens is that you have to, you know.

In quarterbacking your own care you have to tell your story again and again and again.

Because first there's your primary care physician.

Then there's the resident, then there's the fellow.

Then there's the other person who comes in.

And then the social worker drops by as well.

But you're saying one it's one story and then everybody will access it.

And on the provider side people are actually looking at it that way and saying, oh.

I don't have to hear everything again.

- [Daniel] Yeah, so the best part about the way we built our system is we built it around a client securely.

So, the network is comprised of all of these nodes around a client.

The client has to consent to be part of the network.

They want to know that their information is secured.

Again, we start with veterans and we protect our information like gold.

So, we had to make sure that not only about HIPAA compliant but, right.

There's a lot of permissions that have to be controlled around medical information versus nonmedical information, right.

So, it's not just an open thing.

It's very protected around who should see what.

And the purpose of that is so that when Metro Health or Cleveland Clinic sends something out to the food organization.

That food organization takes it on.

They're not just getting a name.

They're getting the story so that the client doesn't have to say, oh.

What type of food do you need?

And all of these things over and over again.

And then the food organization.

If they expose another need like housing, they get it over to housing.

And then that person doesn't have to say your name, email, phone number, all of those things over and over again.

Because it's already stored.

Now, everyone, you think about this, becomes part of a care team.

And a new type of care team that has not existed before.

And so, it's around all of these different types of organizations that are now empowered to work together.

Where otherwise it would've been all individual stories and phone calls and everything else.

- In the cities and I'm sorry that I cut you off before.

About like the success- - [Daniel] Yeah, sure.

- In the cities where you've worked the longest.

Are they finding that communities are healthier and that costs are going down?

- [Daniel] Yeah, so that's a great question.

And when we talk about the word or the term ROI, return on investment.

It means very different things to very different stakeholders.

And so, let's talk about community based organizations for a second.

We talked about the patients.

So, that's a very clear one, should always focus on that.

But we're saving about 85% of their administrative time, right.

So, they were spending hours and hours.

When someone walked into the food organization food wasn't the only need.

There's always more than one that's going on.

And so, when they tried to connect people externally it was paper, phone calls, Googling a list and then printing something out.

And then never knowing what happened on the other side.

And we replaced that for about two minutes, right.

And then you get alerts back.

Which is, you know.

It sounds crazy but it works really well.

And so, from an efficiency perspective and the data impact reporting that the community based organizations get is really impactful.

On the medical side, one thing that was published in Forbes was it on a thousand patients.

Just looking at a thousand patients before and let's call them clients.

Clients that were not served in the network prior and then a thousand that were served in this community network and in New York.

A 16% reduction in emergency room visits.

So what did that mean?

That means organizations in the community all had the ability and the tools to surround these clients.

Serve these needs without clinical intervention, right.

So, that means we created this ecosystem, this infrastructure that supported these people.

And they became the first point of call before they walked into an emergency room visit.

You know, whether it's for food or cause they were homeless or for any other types of things that were not just related to medical, pure medical care.

And so, that's an ROI.

That's a cost savings.

And I hope we get to talk about where the future is going around this.

As we do bridge these two big systems of health and social care together.

- Dan Brillman is founder and CEO of Unite Us.

They're here in Cleveland now through a program called Unite Ohio.

A partnership between Metro Health System and the Cleveland Clinic.

And if you'd like to join our conversation with a question about how this will work.

How it will change the way healthcare is delivered for our most vulnerable neighbors.

Please send a text to (330)541-5794.

That's (330) 541-5794 for your questions.

Or if you're on Twitter you can tweet them @thecityclub and we will work them into the program.

This is your City Club Friday Forum, I'm Dan Moulthrap by the way.

Dr. Bharmal, what are the metrics that you and your colleagues at the Cleveland Clinic are focused on?

- [Nazleen] Yeah, we're really interested in.

We've been screening our patients for sort of these health related social needs, social determinants of health.

And we've been referring mainly through social workers to community organizations.

What we don't know is what happens afterwards.

So, we are extremely interested in the referral outcomes.

And just as Dan mentioned, we are interested in three different levels.

The patient experience, does this increase trust?

Are we seeing better health outcomes?

Are we seeing that their needs are getting met?

We're interested in organizational outcomes.

Such as whether or not healthcare costs are going down.

Or unavoidable use of the emergency department is happening because social needs are being met.

And we are definitely interested in the provider experience.

Are we seeing decrease in burnout or emotional exhaustion from patients that have high social needs as well as complex medical conditions?

And knowing that we feel limited in what we can do in the clinic.

Because we are unable to meet the other barriers that help the patients thrive.

- Sue Fuehrer over at Metro.

I want to ask you about kind of how this fits with the philosophy that Dr. Akron Boutros, President of Metro Health has been talking about.

For years he's been talking about just kind of pushing healthcare upstream and out of the hospital back into the community.

And this, on its face.

And I hope I'm not overstating this but this sounds like Holy Grail type stuff.

That, you know, in terms of really connecting the work of the hospital with the patient's actual needs out in the community.

Where the fact that these social determinants can affect, I guess, the studies say 80% of their health outcomes.

- [Sue] So, you know, Akron has done a great job saying that none of us can do this alone.

And that it's only through partnership that we are going to be able to make a difference.

And I think that that's the advantage of Unite Us.

So, we already have 72 community based organizations across Northeast Ohio that are participating.

It literally grows, I think, every day.

And so, what is the beauty of this?

Is that it helps us get out into the community.

And as Dan said, patients tell their story once.

And then the community based organizations have that information.

And then, now that we're getting to the point where they're responding and the clinicians can see this.

We'll be able to evaluate outcomes but we're also going to be able to identify where we have pockets or gaps in our communities.

You know, where do we need a food pantry or where do we need a grocery store?

You know, what corner is there not adequate transportation so that people can get out?

So, we're gonna really, as a community, be able to delve really into the data that will help us really have information to determine what kind of services we need across our community.

Where we have redundancies and where we have gaps.

- Dr. Bharmal, turning back to you for a second.

And in the screening process I'm very curious to know how it functionally is working on some of the highest need areas in our community?

The ones we talk about quite a lot here at The City Club.

I'm thinking about lead poisoning, infant mortality and adverse childhood experiences.

Which we know can have these sort of incredibly devastating longterm effects on adults who have a certain number of, what are referred to as ASIS.

But are you screening for those things?

And do we have enough community based organizations involved to address those needs?

- [Nazleen] These are excellent questions.

- [Dan] Well, thank you.

- [Nazleen] So, I'll just take it one by one.

For just lead, which is about.

Not just about mitigation screening when it's already too late and then intervening.

But it's actually about going more upstream.

That's what I think these conversations allow us to do.

Which is really get to the root heart, root cause of why we're seeing some of these conditions happen.

So for lead, I think it will definitely help us understand.

We already know where there are pockets for housing.

We are screening right now.

But screening is a little bit more downstream, right.

Once you've already identified lead in a developing brain.

All you can do is mitigate at that point.

- [Dan] Right.

- [Nazleen] And so, is there an opportunity to think about really just intervening in the homes.

Same thing with adverse childhood experiences.

We know it has both short term and long term consequences.

And we do screen for adverse childhood experiences.

I think one of the challenges is, which this network actually allows and this care coordination allows is, okay.

Who do we refer to now that we're screening them?

Yes, we can refer people to community mental health providers.

But is there something that we can do on the front line once we're screening to do an intervention right then and there?

Can we have conversations as a region to talk about social and emotional health?

And what kind of interventions we should be doing either at the family level, the healthcare level, the school, the workplace to address some of these issues.

- The universe of nonprofit organizations, 501c3s, community based organizations.

These all refer to the same thing.

But the universe of those in Cuyahoga County is somewhere in the neighborhood of 6,000.

Not all of them are direct care providers or the kinds of organizations that would be a part of this network or need to be a part of this network.

But the number is certainly far greater than 78.

So, which organizations?

Which kinds of organizations should be thinking about getting involved here?

Sue, Sue Fuehrer.

- [Sue] Sure, you know.

Food, transportation, housing, utilities, digital connectivity, education, employment, legal, behavioral health and other health care.

The Gathering Place, for example, takes care of cancer patients.

We work closely.

You know, they may need wigs or things like that.

So, really the there's a big huge gambit of organizations that are extremely helpful.

And then the beauty is is that through this network.

Or as I said before, the organizations can refer to each other too.

So, it doesn't have to be health related needs also.

So again, we're out trying to get the word out and we are relatively new at this.

We've implemented it in the midst of a pandemic.

And- - [Dan] Which is both great timing and terrible timing.

- [Sue] Yes, you know, actually somebody that was involved said early on.

They said, we knew we needed this before the pandemic.

We did start convening.

We were this close right when the pandemic hit of signing.

And they said but boy, do we need it now more than ever.

Boy has the pandemic really demonstrated just how fragmented our system is.

And when you lose the face to face interaction.

And you're solely relying on the phone or the electronics.

Unite Us makes it a whole lot easier.

- Dan Brillman, are there.

I'd love to hear about organizations outside of Ohio.

And I should mention right now.

Somebody should mention the URL.

We haven't even mentioned that.

If people want to find, I think it's Unite Ohio.

If they Google Unite Ohio you will find it, right?

Like let's all agree that that's the quickest way.

Dan Brillman though, turning to you and somebody will send me the URL in a second I'm sure.

Could you share a story about a sort of unlikely organization that joined the network and what the impact that that had on their clients and their organization?

- [Daniel] Yeah, absolutely.

I'll start with the URL, Ohio.UniteUs.com.

- [Dan] Thank you sir.

- [Daniel] That'll be a helpful one.

Yeah, of course.

And I like to always bring up churches.

That's been a really interesting journey and then schools as well.

And I bring these up because they're access points.

You may not think of them as just service delivery organizations.

But where do people show up every day or every week, right?

Where they may talk about their needs with someone.

It may be a school nurse.

It may be the pastor, right.

These are new places.

These are not doctors where you have to go to the doctor to tell them about your needs.

These are other places where they show up.

And they become organizations in the platform because they see the need all day.

And so, I like to bring those up because it might be that that light bulb.

Oh, that's obvious that they should be part of it.

But these are all organizations that may not electronically receive every day.

But they for sure are access points where otherwise it may be a much more emergency response to those needs where they can be solved.

Because someone said something in a place of worship or in a school setting with the school nurse, as an example.

- Sue Fuehrer, go ahead.

- [Sue] I was just going to say the community development organizations too.

We've had several of those join.

And they are also another point that see a lot of people that have need and it makes it a whole lot easier for them.

- You know, I've been thinking about.

As we've been discussing this.

My brain is going to some conference calls that I've been on around efforts to increase vaccination rates.

And make sure that everybody has access to the mass vaccination clinics that have been at the Waldstein Center.

Sue Fueher and Dr. Bharmal, you may have been on the same conference calls that I was on.

But it seems to me that those are the networks.

Like those are the groups in every organization that was funded at any point through like the COVID-19, the Greater Cleveland COVID-19 Rapid Response Fund.

Should be, if they're not already part of the network.

They should be heading over there right now to check it out.

And it appears to be pretty straightforward to sign up.

- [Sue] Yes.

- Yes, okay.

Great, well thank you for confirming my suspicion about how easy it is to sign up.

We're talking with Sue Fuehrer at Metro Health.

She's the President of the H.O.P.E Institute there, which stands for Health Opportunity Partnership and Empowerment.

Dr. Nazleen Bharmal is a with the Cleveland Clinic.

She's Associate Chief of Community Health and Partnerships there.

And Dan Brillman is our is our man from out of town.

He's the CEO and founder of Unite Us.

Unite Us, if you've just joined us, has come to Cleveland to partner with these two institutions.

They hope to bring in more healthcare institutions.

And I suspect that the reason it's called United Ohio and not just Unite Cleveland is that they have bigger aspirations even beyond greater Cleveland as well.

If you'd like to join our conversation.

If you have a question about how this works.

How it will affect our neighbors and how it might affect you and your organization or your life.

You can text your question to (330) 541-5794.

The number again is (330) 541-5794 to text your question.

And if you're on Twitter please tweet it @thecityclub and we'll work it into the second half of the program.

It's your City Club Friday Forum.

And the Q and A starts now.

So, here's a question.

In exchange for tax exempt status hospitals are required to provide a community benefit and to report that on their annual tax forms.

We know most of the community benefit spending from hospitals is for financial assistance.

Example is the differences between what Medicaid care costs and what it actually pays for.

But why not devote some of that spending to actual upstream factors and investment into the physical Cleveland community?

Things like lead abatement for instance or mitigation.

Creating lead safe housing.

Rather than just dealing with the effects of these issues when people eventually come into the hospital, Dr. Bharmal.

- Yeah, we can do both.

And we should be doing both and we are doing both.

And I would say that all of our healthcare systems.

We are very fortunate in Cleveland and in Northeast Ohio are doing both.

So, we are not just screening people and then addressing their issues medically.

We are also talking about taking part of our investment and putting into housing and doing lead abatement.

Very exciting time.

More and more healthcare systems are joining this effort because we all recognize that housing is health.

- [Dan] Sue Fuehrer.

- [Sue] I think we've seen Metro in action with actually building houses near the Metro Health System in the Clarksville neighborhood.

We just started Via Sauna, an $80 million project with 72 affordable units that will be finished in 2022.

And on the first floor is actually gonna be an Economic Opportunity Center.

Where people from the community, anyone from the community can actually walk in and get the assistance.

And we will have a presence there, Institute for H.O.P.E.

- Thanks, Dan Brillman.

A question for you.

While collaborating on Unite Us is obviously good alignment and an important information sharing step for addressing short term health care provision and accessing social services.

How does it lead to investments in mid and longterm upstream solutions needed in both community conditions and in policy?

- [Daniel] Yeah, that's a great question.

And Unite Us is, while a technology company.

We're really building a new model of care.

And it goes way beyond just the connections and the outcomes that we're tracking, right, that are getting people healthier.

What we're really moving towards is a new type of model that brings social care organizations, these community based organizations to the same priority level as a doctor.

And what that requires is policy shifting.

It requires new types of payment models of how to reimburse these organizations.

If they're doing great work and they're saving hospitals money and the government money.

How do we how do we fund them and reimburse them similar to how businesses get paid or doctors get paid?

And that's really what we're working on.

You're seeing that happening across the country from a policy shift.

Where no longer is it just about what is the charge for the knee surgery?

It is organizations like insurance companies can start paying for things that ultimately improve health and keep people out of the hospital for unnecessary utilization.

And so, the next step in the journey of our company and what we'll be doing together over the long term is how do we balance the human service portion, right?

And how do we elevate those types of organizations that are truly improving health and balance that with medical care as well?

And that's the exciting part about where the industry is going and policies moving that way.

Obviously the administration, new administration and office as well.

And you're seeing it obviously on the ground.

People need these services and you're seeing philanthropy, healthcare dollars all looking towards that.

Now, the goal is to centralize it.

How do we all get to be talking the same language and investing in things with data, using data?

- Another question for any of you really.

But Dan Brillman, we'll start with you.

What is next for Unite Ohio?

I alluded to this earlier, that it's Unite Ohio and not Unite Cleveland or Cuyahoga.

So, will other health systems in Cleveland and across the state joined the network to serve more people?

Can you talk more about that?

- [Daniel] Yep, yeah.

So, a network is as great as the network.

So, the goal is to always improve and grow the network.

There's never a stopping point to a network.

It's always evolving, it's always maturing.

And it requires a village.

It takes a village to do this type of work.

And so, not just more healthcare organizations.

We need different types of government organizations.

From city to municipalities.

And then also more services that that go outside of the counties that we're just starting in.

So, of course the goal is to expand that across the state.

And we've heard from the organizations that are in the network already that they want to expand.

They want more connectivity even outside 'cause it's not just county based.

People can travel to services, people move.

And so, we want to make sure the network is there to serve the needs.

And so, that requires, of course, continual growth.

- Is this something that you, oh.

Dr. Bharmal, go ahead.

- [Nazleen] Yeah, for Cleveland Clinic we're actually invested in 13 counties in Northeast Ohio.

So, that will be live.

We have not actually started implementing Unite Us but we've been learning a lot from Metro's experience.

We will do six counties by end of July.

And then all 13 counties in Northeast Ohio where we have a presence.

This is very exciting.

Includes rural and urban areas.

And it's part of our overall community health effort which is around heal, hire and invest.

- Sue Fuehrer.

- [Sue] Certainly, we continue.

We are the most experienced.

So, we continue to listen to our staff that are making referrals and are saying, hey.

You know, this organization is not in the network.

And we work very closely with United Us to reach out to those networks.

So, every day we are learning, we are growing.

We are excited that the Cleveland Clinic is going to join the network throughout those additional counties.

Because that will certainly bring more organizations onto the network.

And as Dan said, the network is only as strong as the people that and the organizations in it.

- There are a lot of listeners in greater Cleveland who are wondering why university hospitals or St. Vincent Charity Hospital are not a part of this already or yet?

Can you confirm or deny anything about that?

I mean, do we know?

Is it safe to assume that conversations are happening Sue?

- [Sue] Yeah, you know.

We've had lots of conversations and I think everybody is looking at it.

Certainly it's been a really big year for healthcare institutions and everybody's had different priorities.

But we are engaging not only the healthcare systems but federally qualified healthcare centers.

We've had some discussions with them to try to get them on board too.

So, we're certainly talking and sharing our experience with everyone.

- Great, another question here from our listeners.

And if you do have a question please text it to (330)541-5794.

The number again to text your questions about our topic today, (330) 541-5794.

If you're on Twitter please tweet your question @thecityclub.

We'll work them all in.

Once a patient is referred to a community based organization.

Can the healthcare providers who made the referral monitor the status of that referral within the technology?

I'm seeing a lot of nodding.

Nobody on the radio can hear you nod.

- [Sue] Yeah, yes.

- [Nazleen] Yes.

- Dan Brillman, go ahead.

- [Daniel] Yeah, absolutely.

I mean, that's the foundation of the product.

Is can you prove that the person got the services that they needed?

And that's the ultimate part of that.

And so, of course, anyone that refers and not just from health care out to the organization.

But even between organizations.

Housing and food, they want to know did that person ever get there or not.

What actually happened?

And so, these are the critical things around why technology is so important.

'Cause it answers those types of questions that used to be very offline, very manual.

Took a lot of time and ultimately was a burden on the client in need.

So, that's fundamental to the work that we're doing and we always have to answer that question.

- And- - [Sue] You know, and we've.

- Go ahead, Sue Fuehrer.

- [Sue] Seen this, you know.

Real time where a referral has not been answered timely.

So, then we know to reach out to a different organization.

So, that's helping us hone where we refer, which organizations we refer to.

And it's also giving us real time information.

Which organizations are able to respond to our needs and which ones aren't?

- And when a patient comes to you with these unmet needs and you're able to establish that referral Sue Fuehrer.

Is there somebody on staff at Metro who is assisting and making sure that the patient, the client, our neighbor gets to the service, gets to the organization?

Not just like looking and seeing if it happened.

But actually assisting in that process and helping to manage the care.

- [Sue] So, you know.

Yes is the short answer.

And I think we triage.

So, there are many patients that it might work and say here, you know.

There's a food pantry down the street that works.

For some patients they need more touch and they might have many, many social needs.

And that's where a community health worker or social worker will step in.

But what we're finding is that for many of our patients Unite Us is a perfect answer.

Because they can put in what's going on.

The agency can refer back and then everybody sees.

And if that's not met then we can allow our staff to work at their highest level of the license.

And then that social worker can reach out and say, okay.

This patient wasn't able to connect by themselves.

Wasn't able to get what they need.

So, let's step it up and hammer clinical intervention.

- Dan Brillman, a question for you.

Which I'm sure the answer is yes.

So, I'm gonna ask you to explain more.

But have you experienced any regulatory obstacles to sharing information with community based organizations?

I would imagine that there is nothing but regulatory obstacles that you've had to figure out.

- [Daniel] Yeah, I disconnected for about two seconds.

- [Dan] Okay.

- [Daniel] I heard regulatory obstacles.

- Yeah, that's the question.

Talk about the regulatory obstacles and talk about how you kind of untangled that knot.

- [Daniel] Absolutely and we just submitted a letter to ONC and OCR.

Because they're requesting actual changes to law which alleviate the burden of the silos of information sharing.

And there's a lot to be said there.

So, first and foremost.

The patient has to direct their consent.

Which is a new process between stakeholders that never talk to each other electronically.

So, first and foremost.

That is paramount to our work, that is required.

The second part of that is that the organizations that we onboard.

Why we talk about quality and accountability is because they have to be on boarded specifically by the types of services they provide.

And this gets into the very detailed services around substance use.

Which is another law, 42 CFR Part 2 of how we treat behavioral health information and substance use information.

So, there are very protective laws that even go beyond HIPAA related to that.

So, we had to build features around what's called sensitive service types, right.

So, it can't be shared with the network.

It has to be direct relationships because that is what the law states.

Is that a burden on clients and need ultimately sometimes?

Yes it is and we know that.

But technology can secure data that way.

And we've built this system to ensure that only people that should see what they should see, see it.

Otherwise, they should not see it.

And that's an important factor of this.

While it is a network.

We want to make sure we don't duplicate services, which is really important.

Is this person already getting a service?

And ultimately when we talk about things like legal services.

You know, can I tell the Cleveland Clinic what a client's legal service is?

No, I can not, right.

That's bound by a different confidentiality.

But they want to know that a legal concern is taken care of, right.

And that may be good enough for a doctor to understand that it is being taken care of.

So, all of these things over eight years.

It is unbelievable how many features and permissions that we've had to build.

I think over 7,000 that have to be controlled every single day.

And how secure this network has to be for this to work.

But what we're seeing ultimately is that laws are changing because we understand how burdensome it can be.

Even just in the medical world of information sharing.

Just my medical records, let alone what's my social care record, right.

Is there one?

And so, now we're bringing that all together to say how can we build the best experience for consumers that have needs?

And how do we protect that information?

How do we connect them?

And then how do we ensure that they get those services every time?

- I wouldn't be surprised if your legal department is as large as your coding department.

- [Daniel] And is the best department for sure.

They work very, very hard.

Yeah, we could not do that without them.

- Access to educational opportunities and affordable quality childcare.

These are two things we've talked about a lot at The City Club.

Our two other social determinants of health.

How is Unite Ohio working to address those particular issues?

- [Sue] So- - Sue Fuehrer, go ahead.

- [Sue] Sure, we have been really working closely with Tri-C Cleveland State trying to make sure when we screen our clients.

You know, we were actually in the COVID clinics, the vaccination clinics.

While you wait for 15 minutes after you get your shot.

We were asking people to complete the SDOH survey.

So that we could follow up real time.

You know, and the number of people they're saying unemployed, seeking employment is huge.

So, educational opportunities, employment opportunities.

So, we're really targeting them.

We've just started working with organizations like Head Start and things like that with childcare.

What we have found so far is the biggest need, it is a little bit frustrating, is housing.

You know, it's a big ticket item.

It's really tough.

We've got lots of money coming into the city to address housing.

But it's really hard to complete all the paperwork and the applications.

And connect those patients with timely housing.

And I think we're only gonna see that get worse.

- Is it family housing or is it is single adult housing?

- [Sue] I think it's both.

- Ah ha, that's fascinating.

But that is as you quoted Dr. Boutros earlier, housing is healthcare.

It really is.

Dr. Bharmal, how about private practices?

How can they become connected with United Ohio?

We talked about federally qualified health centers earlier.

But what about private practices?

- [Nazleen] So, we actually are having a conversation.

We have a quality alliance of physicians who are in private practice but affiliated with the hospitals.

And I think they are very excited to learn about Unite Us and be part of the network.

As long as you're on Epic and part of the electronic health record actually.

You can have access to Unite Us.

The main issue is that for them it's who is doing the screening?

And then who is actually responding when somebody identifies a need?

And so, instead of having to fax paperwork over to like a community based organization to meet the need.

We can just now do it electronically.

So, private practices are part of the conversation as well.

But as long as they're affiliated.

- [Sue] Just one point of clarification.

You do not have to be an Epic user.

Unite Us is EHR, Electronic Health Record Agnostic.

And that was one of the key features because we do have different health systems that are on different electronic health record platforms here in- - [Nazleen] Yeah and then just on that.

We have users that are gonna be in our network that are not even on Epic.

And so, are gonna be using the web based.

But they directly interface with community members.

Whether or not they are patients because they do a whole host of community based programming.

So, that was really important to us as well.

To make sure that we had users that didn't even have access to the electronic health record but could use a web based platform.

- Dan Brillman, you earlier mentioned that you're in 42 states.

What's going on with those eight states that haven't welcomed you in yet?

But this is the first.

So, is Ohio then the 42nd state that you're in?

- [Daniel] I think it was the 41st.

- 41st, okay.

So, you're obviously growing.

But what holds places back from engaging with you?

- [Daniel] Yeah, it's a great question.

You know, before it was we needed a core partner to kind of bring us there in the past.

And so, the conditions have to be right.

And that's an important factor.

And I would say in all 50 states, it's right.

But the question is how fast can we get there now as a company?

And so, for us we used to say, okay.

A customer or a partner wants to do this.

They're going to come to us.

And I think those tables have turned a little bit because of COVID.

And so, we are building actually in those states that we are missing as well.

Because ultimately people need services.

And so, we know that once they build it people will come and we've proven that.

Like a state like North Carolina.

Just within two years we have almost, I think, every health system, almost of every health system.

Every insurance company and thousands of social services, public health.

All the organizations physician practices.

FQHCs, they're all in the network and they've been in the network.

Now, it takes time to get to that level of scale across an entire state.

But we know we can do that everywhere.

And we're really on a mission to make this a standard for generations.

And so, for that to happen you have to build that infrastructure first.

And we said the time is now to do that.

- What is your connection with the Medicaid system?

I mean, because it seems to me that that is a lot of the population you're trying to serve.

- Yeah, so we serve all populations.

We work in the Medicare, we work in commercial space.

But Medicaid was where right after Veterans it was it was the next step for us to work with Medicaid health plans.

And we did that big in New York.

Moved into, obviously North Carolina was a big one.

And then in Oregon I think we work with almost all of the Medicaid health plans now.

And the great part about this work is that it's not just about one health plan saying I'm doing this.

And then no one else does it.

Like eventually everyone says why wouldn't I be doing this?

Because it's not like everyone's on a Medicaid health plan forever.

They move plans, right.

People shift, they move into Medicare.

They may become both.

They may go into commercial.

And ultimately everyone wants them healthy.

People don't want anyone to be costly.

So why wouldn't we all be involved in this?

And that's led to a great governance that brings everyone together to make shared decisions together.

Even if they're competitors, which is important.

So, Medicaid is a big play for for the organization.

And to be able to improve people's health.

And seeing a lot of also very quick wins.

There are people that need help today and we can get them help today.

- Excellent, has Unite Us found a way to bill insurance providers for this program?

And if not, how will healthcare organizations, especially smaller ones, manage to pay for this?

- [Daniel] Yeah, so we've started to.

A couple of states that I'll point out that that allow for this now.

So, North Carolina through Medicaid has what's called the healthy opportunities.

Which is a $650 million of reimbursement for social services.

We're literally using medical dollars that would otherwise be used for a doctor's visit or a surgery.

For rental assistance, for housing, for transportation, for nonmedical services.

And so, that came through from CMS.

And so, that is a great stepping stone to how you reimburse services.

Now, that is $650 million.

We can do a lot with $650 million in North Carolina But in California next year there's what's called in lieu of services.

Which is the health plan can say I can offer and actually provide any of the social types of services.

And get reimbursed under medical care for those things.

That is very new.

So, this market is moving very quickly.

California is, almost a country, right.

It's a huge state and with a lot of population.

And so, allowing health plans to do that and that's in Medicaid, right.

That's really important.

A couple of years ago Medicare Advantage broadened the scope of what they can pay for.

So, now they offer all these supplemental benefits to be competitive.

To offer better patient and member experience under Medicare Advantage, which is great.

So, that's already starting and that's grown by, I think, 300% of what health plans are offering their patients, which is really great.

That's around reimbursement.

I mean, these are things that have to get reimbursed.

This is food delivery and things like that, which is great.

- You know, this brings to mind a question about kind of why we haven't done this already.

In many ways this seems sort of super obvious.

And the thing that was missing, I guess, was the technology.

But it never required technology to build a referral system that works.

And this is essentially a very robust referral system.

Dr. Bharmal, why haven't we done this yet?

- [Nazleen] Yeah, I think right.

We're just in a right time right now.

The incentives are aligning in healthcare.

Partially, largely driven by the Affordable Care Act.

We're seeing more and more interest in reimbursing.

Recognizing actually, as you mentioned, that 80% of the population's health is outside of medical care.

And so, being able to reimburse that to keep people healthy.

Moving the shift to population health which means instead of delivering services and fee for services.

Moving to value and being responsible as a healthcare organization for the outcomes, the health outcomes.

And then if you're responsible for the outcomes it doesn't matter how you get there.

You want to make sure that that patient is healthy and there's this greater recognition.

That that comes from things other than medications and doctor visits.

It actually comes from stepping outside of the healthcare system into the things that we've been talking about, these social determinants.

Housing, utilities, food.

That have a huge influence on health.

So, I think all of these incentives and largely driven, quite frankly, by the Affordable Care Act.

And moving towards value is part of the reason that we're seeing this.

Basically you cannot.

The health of a health care organization is inextricably linked now to the health of the community and the patients surrounding it.

- Sue Fuehrer, when you were at the VA I'm sure you were part of conversations like this.

- [Sue] Yes.

- And in my experience here in Cleveland for the last 15 or 16 years.

I mean, I've been a part of many conversations about these sorts of things.

Going back to 10 years ago when we first began to talk about how zip code is sort of healthcare destiny or health outcome destiny.

Does this feel fundamentally different?

I mean, I really hope that it does.

Because if it doesn't we're just spinning our wheels.

But how does it feel to you?

- [Sue] So, it certainly does.

You know, and coming from the VA healthcare system.

We were graded on how healthy our veterans were going back decades and really looking at population health.

And the VA has had the opportunity to look at vocational rehab and homelessness.

And really moving upstream well in advance of many of our other clinical partners.

Which is one of the reasons why I'm at Metro now.

To really take advantage of some of those things that I learned and move them forward.

But I think Unite Us is really fundamentally different because it's making it a lot easier and more efficient for the frontline staff.

The people that need to make these connections.

You know, there's not little pieces of paper.

It's not a directory on the cubicle wall saying, okay.

Well, what's the number now?

Is this organization still open?

What are the hours?

You know, asking the patient to make the call themselves.

Asking the patient to repeat the story to several different places.

And then really not knowing what resulted in that.

So, you know, the goal of this is through this bi-directional platform that is transparent.

And the other thing we haven't talked about is every patient is a unique identifier.

So, there could be 10 Jane Doe's.

But each one of them is going to be unique.

So, if Jane Doe goes to the clinic or university hospitals or Metro.

We're all going to be able to link and see what was done for Jane Doe.

Which I think is really, again, making us a better health record rather than an electronic health record.

You know, whole person health records really augmenting.

So, I do think it's fundamentally different.

- Dan Brillman, as you look ahead you said this is a generational challenge.

What is the...

I keep using this metaphor of the white whale 'cause I really loved Moby Dick.

But what is your white whale?

Like, what are you after?

You've built obviously a very strong platform that is changing lives and changing healthcare.

But there's probably, I suspect, a bigger thing out there you're trying to conquer.

- [Daniel] Yeah, one thing I'd like to look at as the past.

And what's an example of something that's happened 30 years ago.

And I bring up mental health as an example of something that was not paid for as a medical service 30 years ago.

You walked into someone's house.

You paid him some cash, right.

You got whatever you needed.

No one questions that mental health and substance use treatment are reimbursed services today, right.

Now, there's not enough of them.

We can understand that, right.

And we're still working on supply but no one questions that.

And so, how do we take all of these social care organizations and they services and bring them to that level?

And so, that's the economic part of that.

And I think we're going to get there.

I will feel great when those organizations are treated the same way.

That that's one part.

The second part is about the patient.

You know, love them or not everyone.

A lot of people use Amazon.

And so, we think about our customer experience using Amazon and I have Prime.

And so, I get upset when my package isn't here in a couple of days and I order something.

And so, why shouldn't our experience as patients be like that?

Think about what Amazon did with supply, right.

They built the whole logistics system.

They figured out all the nodes of who's who sells all the things in the world and centralized it for the person buying it.

We should have an experience for integrated health and social care in that same experience.

So, that would make me feel good.

It gives me the chills to talk about it like that.

But I think we all should drive towards that.

And that requires some baseline infrastructure to be able to do that.

I think we're in the early days of that.

But we're making so much impact already that there's line of sight to that type of experience.

- Dan Brillman is the co-founder and CEO of Unite Us.

They have just come to Ohio this last to form Unite Ohio.

Starting with the Cleveland Clinic and Metro Health System.

Sue Fuehrer with Metro Health.

She's President of the Institute for H.O.P.E, Housing Opportunity, something and Empowerment.

What is the P?

- [Sue] Health, opportunity, partnership.

- Health, opportunity, partnership, empowerment.

I apologize for not getting that right.

- [Sue] I'm gonna approach you next time I see you.

- Dr. Nazleen Bharmal is Associate Chief of Community Health and Partnerships at the Cleveland Clinic.

Thank you so much all three of you for your time today.

- [Nazleen] Thank you Dan.

- [Sue] Thank you.

- Thanks also to our members, sponsors, donors and others who support our mission to create conversations of consequences that help democracy thrive.

We've got some great conversations coming up this month.

Next Friday we'll talk with three local leaders in the Asian American Pacific Islander community about the recent rise in hate crimes against that community.

And on May 20th it's our annual State of the County Address with Cuyahoga County Executive Armond Budish.

You can find out more and see what else is coming up at cityclub.org.

You can check out what you missed there.

Or on PBS Passport, Roku, Amazon Fire Stick, Vimeo and of course our YouTube channel as well.

I'm Dan Moulthrop, stay close in your hearts my friends.

We will be close in person again very soon.

Our forum is adjourned.

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