Unite Us: Connecting Brown County Communities

By Erika Ditzman

Achieve Brown County is partnering with Unite Us, a nationwide company that builds coordinated care networks of health and social services to provide clients with wrap-around care. This partnership with Unite Us is one more way that Achieve Brown County is striving to improve connections in the community and inspire equity across Brown County.

The current system for social supports forces clients to relive their experiences each time they tell their story, as no electronic database is currently used to connect the social space. When the Unite Us system is operationalized, a client only needs to tell their story once, and it becomes available across the confidential, digital platform. This makes for navigating the social system much easier.

Once the individual’s needs are determined, they can be referred to multiple community resources simultaneously and securely. It is when their needs are met that this becomes a successful closed looped referral system.

Outcomes of the system are monitored through data. This data is used to better serve the community and drive social impact. The outcomes are then fed back into the system to further improve it. This is what is called a feedback loop and leads to equitable access to community resources. In the future, our ABC Action Teams will be able to utilize data from the Unite Us System as they work to drive system change and improve social determinants of health.

Unite Us will be most successful with a wide representation of nonprofits. The platform comes at no cost to community-based organizations. For more information about Unite Us, visit or contact Katie Hess at

Words to Know

Wrap-Around Care:

Wrap-around care involves team members who work collaboratively to develop an individualized plan of care, implement this plan, and evaluate the success over time.

Coordinated Care:

Coordinated Care is the organization of patient care activities between two or more participants (including the patient) that are involved in a patient’s care, used to simplify the appropriate delivery of health care services.

Closed Looped Referral:

A closed-loop referral is one that successfully secures the right resources for patients, ensuring that the patients’ needs are met.

Feedback loop:

A feedback loop is the part of a system in which the system’s output is used as input for future operations.

Social Determinants of Health:

Social Determinants of Health are non-medical factors that influence health outcomes such as:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable, quality health services



Neuman, D. (2021, August 10). What is coordinated care? Clinical First Electronic Health Record | Elation Health. Retrieved November 4, 2021, from,delivery%20of%20health%20care%20services.

Singh, A. (n.d.). Spotlight on SDOH Data: Closed-loop referrals for health-related social needs. Activate Care™ Blog. Retrieved November 4, 2021, from

World Health Organization. (n.d.). Social Determinants of Health. World Health Organization. Retrieved November 9, 2021, from


Published: November 10, 2021