Many states struggled to keep up.

But North Carolina had introduced an online social service referral program, called NCCARE360, in a handful of counties in 2019 as part of its innovative approach to the social drivers of health. So the state sped up the rollout and used the program for pandemic emergency response — everything from food delivery to wage replacement for families that had to isolate or quarantine.

It worked. The program, Cohen said, became “the glue, the infrastructure, the backbone” of the state’s response.

Accountability. Transparency. Efficiency. Those are not the words typically associated with America’s frayed social safety net. But what worked in North Carolina is now spreading across the country, and leaders in many states are learning how to change the paradigm.

A growing number of states are turning to high-tech solutions that let social workers and health care caseworkers, in some cases even churches and barbershops, get people the help they need — with a lot less telephone tag and dropped balls.

For Laurie Levasseur, a nurse who is care management director at the Whitney M. Young Jr. Health Center serving low-income people in Albany, N.Y., switching to an online platform was a huge relief after years of making one exhausting and fruitless phone call after another.

It’s added speed, accountability and practical data about where the unmet needs are for patients and communities.

“Sometimes it was an all day thing — you are making phone calls, all eight hours, on one patient,” Levasseur said. And even when she finally connected, there was no guarantee that the needed aid would come through.

Now, said Coretta Killikelly, who works with some of the same patients on health coaching and food access and is part of the same online referral system as Levasseur, “once we get the client, we’re off to the races.”

Several firms offer these platforms, but one called Unite Us, led by a West Point-trained Army vet and an Air Force Reserve pilot, has quickly come to dominate the national market as the pandemic led more and more states to try a new high-tech tool to bridge social and health care needs.

Covid created “unprecedented stress on human and social services,” said Unite Us co-founder and president Taylor Justice.

“A big crisis. And most governments did not have appropriate public health infrastructure,” Justice said. “It put the spotlight on the need for appropriate digital infrastructure. We knew what the model looked like.”

In some states, such as North Carolina and Virginia, governments played a direct role in setting up these systems. Elsewhere, they are brought in by Medicaid managed care plans under contract with states, as well as other health plans, hospitals and philanthropies that treat or support vulnerable patients. Some are public-private partnerships. In North Carolina for instance, the platform is administered by the Foundation for Health Leadership and Innovation, a nonprofit with deep community roots in the state.

Because people in crisis tend to have multiple needs, the platforms enable referrals to move in multiple directions. A health system can refer someone to a housing agency; a housing agency can refer a client for health care. If a food pantry learns that a family who just came in for peanut butter and baby formula is about to have their utilities cut off, it can send out the SOS.

Norman Oliver, who recently stepped down as Virginia health commissioner, said the online tool may do more than cut red tape. He thinks it can transform how physicians think — and act.

“I trained as a family doc,” Oliver said. Physicians are getting better at recognizing how unmet socioeconomic needs harm their patients’ health, but don’t always know how to get them help with things like housing. Even if they do try, “it was like referring them to a black hole,” he said.

“This is empowering doctors to do something — and it makes them think about doing something,” Oliver said.

Unite Us started making inroads into states a few years ago, but it took off when Covid hit. In 2020, 15 states signed on and others expanded. Going into 2022, it has at least some presence in 43 states.

The rapid growth — Justice’s stated ambition is to be in every U.S. county in a year or so — has created some skepticism, particularly in a field like health care, where everyone has a tech-hype horror story.

Doubters complain it’s duplicative or can’t interact smoothly with online-referral programs already in use in some counties or regions, meaning that it can add to, rather than lighten, workloads of caseworkers. Some community-based organizations got a big influx of referrals when these tech systems went live, without the corresponding cash to act on them.

And critics question whether a venture capital-backed for-profit technology firm — even one that boasts of having Hollywood star and “impact investor” Matthew McConaughey involved — will soak up money that could have been spent on these social needs themselves.

“We don’t have enough of a workforce, enough care managers, and coaches. … You can’t hire them away and have them be part of a for-profit solution,” said a social service expert at a government agency who asked not to be named because she was not authorized to talk about Unite Us.

Many health experts who advocate a more active attempt to address social determinants believe doing so will save the health care system money — at least over the long haul. But what specific steps or approaches will generate the best return on investment, or how online programs like these will help, is still being researched — and debated.

The ranks of those who say “at least it’s worth a try” is fast outpacing the skeptics over Unite Us. And some of the people who have been using the systems the longest, including those in the Albany area, say both the technical and the culture change problems can be resolved.

Jacob Reider, formerly the number two official in the federal health technology office in the Obama administration, spent the last few years in upstate New York at an organization called Alliance for Better Health, part of a state Medicaid experiment that addresses social determinants. They introduced the Unite Us platform in a six-county region around Albany a few years ago.

Reider, who recently left the top job at the Alliance but remains in touch, has an unusual perspective, having been both in the high reaches of health tech and the trenches of primary care; on LinkedIn, he describes himself as a “Usability Fanatic.” He’s heard the worries and criticisms but said in an interview that the Alliance has found solutions, including addressing “interoperability” — allowing referrals from outside the system, including via a Unite Us competitor. He won over a lot of hesitant social service workers, still hugging their phone lists, by promising “to make the right thing to do the easy thing to do.”

Karen Smith, also at the Alliance, was one of those skeptics. Not about social barriers to health; a nurse, she had been working on that long before it became fashionable. She just didn’t think Unite Us was the answer.

“I thought, how are they going to do it better than I would? Who are these people? It was the sixth log-in I had to do for my job on a daily basis,” she recalled. She quickly changed her mind, and now works with people like Lavasseur and Killikelly to keep building and improving it.

There was some trial and error. “We started slow and it grew and grew. Now there are hundreds of organizations,” Reider said. And it’s moved from those six counties in and around Albany to an 18-county network, encompassing the Syracuse region and part of the Adirondacks.

North Carolina was a catalyst, but other states aren’t carbon copies. The Unite Us systems vary from state to state, or region to region, and some have added new capacities as their networks grow, baking in more transparency and accountability. Unite Us also just announced a new component to track the available social service funds and make it easier for community groups to get paid.

“You can connect [patients] to a service that actually exists and you get back the information about the referral when they got seen, what got done. It makes it possible to really follow up on it and make sure that these cases get completed,” Virginia’s Oliver said.

Financing the platform differs from state to state. Medicaid plays a big role, especially in states with federal waivers granting flexibility on Medicaid spending. Those relying in part on pandemic relief funds will have to find alternatives as that dwindles. The rest involves what people in this field called “blending and braiding” — pooling various funding streams from both the health and social services worlds into a more sustainable system.

In Nebraska, CyncHealth — which includes the Nebraska Health Information Initiative, an entity that enables sharing patient data from one health setting to another — has led Unite Nebraska, which is part of a larger regional network of seven mostly conservative states in the Upper Midwest.

Nebraska began looking for a broad social service referral platform back in 2018 and opened it in February 2020, “two weeks before we closed our offices,” said Jaime Bland, the CyncHealth CEO. Having built up a lot of patient record and data sharing capacity, “social care was the next logical step,” she said.

“Care coordinators take this on. They push out the needs to be met, cast a broad query” to community partners,” Bland said. “And someone [the client] isn’t sitting there while you try to make phone calls.”

“The workflow is much improved,” she added. “Everyone has one tool, they aren’t responding to multiple queries with multiple tools.”

Oregon was ahead of the curve on recognizing the role of social determinants in health. But awareness, even proactively screening patients for unmet social needs, isn’t the same thing as acting on them. The health plans that started Connect Oregon aim to change that.

“This tool at least in concept offers a potential solution,” said Graham Bouldin, chief quality officer of HealthShare Oregon, which works with the state Medicaid program (though people don’t have to be on Medicaid to get help through Connect Oregon.) “It’s not something in a box somewhere waiting to be used. It’s different when you can put out a referral to four places and have one say, ‘yes, we can do that tomorrow.’”

If Oregon is a pace-setter, Louisiana is a laggard, at or near the bottom of most 50 state health rankings. Some of the big players in the state’s health care sector — health systems like Ochsner and insurers like Aetna — decided they needed a new approach to social needs if they wanted to change that. The goal is to move up to at least 40th place by 2030, said Emily Arata, Ochsner Health System’s vice president of public and community affairs.

Even for well-heeled health companies, getting Unite Louisiana up during a pandemic — and then being hit by record-smashing Hurricane Ida in 2021 — was tough. “It was a difficult time to implement a new, innovative platform — but also the time when the new innovative platform was needed most,” she said.

Now statewide, the network is steadily adding users — by the start of this year, around 600 organizations running 1,000 programs, helping people with food or housing; keeping the lights on; accessing veterans benefits; escaping domestic violence; or getting mental health services.

There’s accountability, visibility and greater collaboration with community groups, Arata said. “It’s a true network,” Arata said. “A two-way street.”

Unite Us co-founder Taylor Justice knows that if he wants to keep rapidly building out his business, he needs to also keep looking at the challenges facing the states and communities that are turning to the company to find and execute solutions. “How do we continue to invest funds back into the community?,” he asked. “How do we get appropriate public health infrastructure on the ground?”

Those questions, whether asked by a tech executive or health system administrator or state official, are the ones being raised again and again now that states are slowly emerging — at least for now — from the recent brutal waves of the pandemic

“When we finally get this pandemic behind us there will be a lot of work dealing with the social impact,” Virginia’s Oliver said. “This will help.”