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Apply now: Health Related Social Needs Community Capacity Building Funding is available.

Priority area: Social safety net

The importance of the social safety net for Columbia Pacific CCO members is unquestioned. Yet the difficulty for our members in actually getting needed assistance made it clear that a more connected system of clinical, public and social care was critical to getting our members the right help at the right time.  

Typically, when our members in Clatsop, Tillamook and Columbia counties had social health needs, they often encountered silos between clinical, public and social entities that created barriers to getting the appropriate care. The expectation was that the member would figure out a way to navigate several disparate systems to get their needs met. It was a trying and uncoordinated experience that wasn’t patient centered.  

What was needed at a broad level was effective and efficient connections between clinical, public and social health care. More specifically, we looked to create a health and care system that would use information and technology to engage individuals, lower costs, deliver high-quality care, and improve member and population health – with an emphasis on social determinants of health (SDoH) and equitable access to resources.  

An answer came through a partnership with a health information technology company called Unite Us. Working together, we helped put the network, security and legal pieces in place for a cloud-based referral system that connects providers in one trauma-informed network.  

This partnership allows for a statewide expansion of the Connect Oregon Community Information Exchange (CIE) project. The collaboration with community-based organizations and social care providers focuses on addressing SDoH, such as housing and food access, in addition to substance use disorder and mental health support services.  

Unite Us supports how we think about and approach the continuum of SDoH, social risk factors and social needs: 

  • SDoH – Promoting economic stability by advocating for policy that promotes housing stability including affordability, quality, support services to protect tenancy and availability; and food security (e.g., supporting federal nutrition programs, advocating for the expansion of healthy food access and nutrition education programs) 
  • Social risk factors – Addressing food and housing insecurity by implementing screening tools in provider settings 
  • Social needs – Referring individuals in need to community health workers, social workers or housing advocates to help them complete SNAP/WIC/housing applications and/or collaborate with community-based organizations, like food pantries and housing support, that can provide needed resources 

Unite Us enables clinical and community partners to send and receive electronic referrals, allowing organizations that provide services such as nutrition, housing and shelter to connect with each other and with clinical providers to determine the best possible outcomes for patients. Partners are also able to better follow the services their clients receive and track outcomes.  

The network launched in the Columbia Pacific CCO region in late February of 2021, and currently includes 13 community-based organizations, with clinical partners close behind. Our parent organization, CareOregon, is participating in efforts to roll out Unite Us statewide, including the Portland Metro and Jackson County regions.   

With a focus specifically on coordinated care organizations, Unite Us allows Columbia Pacific CCO to put an emphasis on whole health, boosting existing work to address social needs across multiple disciplines in a more coordinated and patient-centered approach. 

If you’d like to know more about Unite Us or join the network for free, please get in touch with Keshia Bigler at 

To see the full Regional Health Improvement Plan, click here.  

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