PHP partnership aims to 'close the loop' for residents

Presbyterian Health Plan (PHP), the longest-serving Medicaid managed care organization in New Mexico, is partnering with Unite Us, the nation's leading software company enabling cross-sector collaboration to improve health and well-being, to create the first statewide closed-loop referral system in New Mexico. The closed-loop referral system is designed to address New Mexico communities' diverse health and social care needs more fully.

"Improving the health of New Mexicans means working closely with community partners and local governments to connect people to care that addresses the whole person, from physical and behavioral care to social needs," said Brandon Fryar, president of PHP. "Long-term, a statewide, closed-loop referral system provides more complete data on the needs of New Mexicans. By working closely with organizations across the state, we can address identified gaps in health and social service resources together."

Starting this year, PHP and Unite Us began engaging communities in six counties to build networks of providers, community organizations and other groups. The partnership prioritizes community groups working with pregnant patients, families with young children, Native Americans, people with behavioral health needs, seniors, and justice-involved individuals. In Doña Ana County, PHP worked closely with the Doña Ana Department of Health and Human Services and LC3, a local behavioral health collaborative, to successfully launch their network, Connect Doña Ana, on August 15, 2023. 

Unite Us is a software company bringing sectors together through technology to meet people's needs. Unite Us has active networks in 44 states and has supported statewide, closed-loop networks in several states, including Arizona and North Carolina. Unite Us has invested in New Mexico by building a team from the communities it serves that is working closely with PHP.

"Our partnership with Presbyterian Health Plan is a natural fit, and the need to collaborate across healthcare and wellness services has never been greater," said Erin Willis, Director of Customer and Community Success at Unite Us. "We are aligned on a shared mission of improving the lives of individuals across New Mexico by supporting community-led systems of care, building trust in communities the same way that trust is facilitated between patient and provider, and adequately and accurately capturing the whole picture of a person's health."

Since 2021, Presbyterian Healthcare Service's statewide delivery system of hospitals and clinics has initiated more than two million social needs screenings and provided tailored resource lists to patients who screen positive for social needs. The new PHP partnership builds on this work by using Unite Us' software to screen patients and then refer them to services. Participating organizations refer clients to each other—even if those they refer are not PHP members and do not receive care from Presbyterian providers. Santa Fe Connect, a closed-loop referral system active in Santa Fe, also uses the Unite Us platform to connect community members to services.

Through PHP's partnership with Unite Us, interested healthcare providers across New Mexico can join the closed-loop network. An unlimited number of community-based organizations can join at no cost. To learn more, contact Sankirtana Danner at sdanner@phs.org.

How a Closed Loop Referral System Works The system enables healthcare providers, community organizations and health plan staff to screen community members for social needs like food insecurity or housing instability. If needs are identified, a secure, electronic referral is sent to organizations that can meet those needs through Unite Us' HITRUST-certified, HIPAA-compliant platform. Once a community member receives care, the service organization "closes the loop" by updating the shared platform with the referral outcome. Without this final step, referring organizations may not be aware of what happens after they make a referral.