State Referral Networks Improve Access to Transportation and Community Services

  • Author: Edward Graham
  • Date: December 15, 2021

To better support residents in need of assistance, states across the country are establishing coordinated care and resource referral networks to better streamline communication between transit, health, and social service providers. 

From Hawaii to North Carolina, these referral networks—many of which are powered by software company Unite Us—ensure that residents can easily access a host of needed services without having to shop around for providers. Simply by engaging with one organization, an individual who needs help can be connected with a vast network of statewide services that run the gamut from accessible transportation to health services and housing.

Helping residents connect with resources and services

North Carolina began implementing the first statewide coordinated care referral network in the U.S. in 2019. Known as NCCARE360, and powered by Unite Us, the goal of the network is to improve care for state residents by establishing better communication between health care providers and community organizations. 

While the goal was for NCCARE360 to be fully implemented statewide by December 2020, the coronavirus pandemic necessitated that the network’s rollout be bumped up to June in order to help support residents affected by the economic downturn. 

LaQuana Palmer, NCCARE360’s program director, said the network was geared in part to address four areas of particular concern identified across the state: transportation access, food insecurity, interpersonal safety, and access to housing. 

“Because we have such a rural state, there’s a real need for access to transportation because a number of these communities lack public transit,” Palmer said, noting that almost 80 of North Carolina’s 100 counties are considered rural. “The lack of transportation can lead to issues when it comes to getting to medical appointments, getting food, or just getting around overall.”

There are now more than 2,500 providers and organizations utilizing the NCCARE360 platform, which provides a web of vital services in regions across North Carolina to individuals in need of help. If an individual in touch with one organization about health services needs transportation, for example, then that provider can connect with a transit-focused organization through the NCCARE360 network to make it happen.  

Palmer cited the experience of a North Carolina resident who had never been to the dentist before as an example of the referral network’s impact and ability to bridge a number of disparate services. 

“This individual was able to work with a care coordinator to connect with a dentist, and then the dental office was able to help with setting up transportation so the person could come to their first ever dental appointment,” Palmer said. “Tapping into the network allowed them to set up that connection.”

As the country’s first statewide referral network, NCCARE360 has served as a model for other states that have implemented similar systems. But Palmer said the network is constantly being evaluated and improved to ensure that community providers have the staffing capacity and resources they need to participate in the system and connect with residents in need of help. And, Palmer added, these types of networks work best when they have the full support of community providers and state organizations.

“The work can’t be done without a successful public-private partnership between government partners and community organizations,” Palmer said. 

The benefits of referral networks

With the assistance of $10 million in federal funding from the CARES Act, Virginia Governor Ralph Northam announced the establishment of a statewide referral system in December 2020 to better coordinate care between health and community service providers across the commonwealth. The new network, known as Unite Virginia and built in partnership with Unite Us, expanded upon several regional United Us networks that were already operating across Virginia.

The United Way of Harrisonburg and Rockingham County (UWHR) in 2019 launched the second Unite Us-powered network in Virginia. Known as Empower Harrisonburg Rockingham, the regional referral network emerged from community and partner discussions about an Asset Limited, Income Constrained, Employed (ALICE) Report that outlined some of the challenges facing residents in the local community. 

“One of the things that was identified was the need for better communication and collaboration between nonprofits in our area to make sure clients didn’t fall through the cracks,” said Jo Benjamin, UWHR’s director of community impact.

After connecting with Unite Us to establish the regional network, UWHR worked to streamline communication between community partners by bringing them onto the referral platform. When the state network went into effect at the start of 2021, Empower Harrisonburg Rockingham became a part of the statewide platform. 

Benjamin said one of the benefits of the referral system, particularly after the move to a statewide network, is that it allows for a broader reach of access to resources for needy residents. When an individual who was experiencing homelessness in the area could no longer stay at the local Salvation Army, Benjamin was able to use Unite Virginia to connect them with a Salvation Army in Winchester—previously outside of Empower Harrisonburg Rockingham’s network—that could provide them with housing. 

“Not having to force the client to repeat their stories is one of the great benefits of this, since they can just talk to you once and then you can send out multiple referrals through the network to help them access services provided by different organizations,” Benjamin said.

Way to Go, one of UWHR’s community partners and an early participant in the Empower Harrisonburg Rockingham network before it became a part of Unite Virginia, is one of the few transportation-focused organizations in the county. The nonprofit is unique in the fact that it provides a host of wraparound services for low-income workers, including vehicle acquisitions, support for car payments and insurance, and car maintenance support. 

At 853 square miles, Rockingham County is the third-largest county by size in Virginia, despite only having approximately 80,000 residents. The rural makeup of the county and lack of accessible public transit services outside the city of Harrisonburg means that many residents are dependent upon personal vehicles to support themselves and their families. 

Benjamin Craig, Way to Go’s executive director, said it was “a no-brainer” for the organization to participate in the referral network, since it allows them to better identify individuals in need of assistance through enhanced partnership opportunities. 

“Our clients often need other services beyond transportation,” Craig said, citing food insecurity and affordable housing as several examples. “If an organization’s referral agent hears that transportation is an issue for someone, then they can connect them with us. And if we have a client referred to us who needs additional services, we have the ability to refer them to other community partners for assistance.”

Craig said that the Unite Virginia network allows Way to Go to see how their clients have been impacted by their services, as well as better identify interactions between them and other organizations–data that can be used to strengthen partnerships and improve services. 

While Way to Go has been effectively supporting low-income workers across Rockingham County, many rural communities across Virginia continue to struggle with access to transportation services. Benjamin said the Unite Virginia network helps providers better identify the limitations of existing public transit services and then pass that information on to local and state officials.

“It’s helped us see the limitations of our local transit system, since it allows us to provide information up the line about the requests that go unfulfilled since we’re able to capture that in the Unite Virginia system,” Benjamin said. “And we can pass along that information to localities when they’re deciding what to do with funding.”


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