State Medicaid Program Reports Cost Savings and Quality Boost by Integrating Social Care

By Halima Ahmadi-Montecalvo, PhD, MPH, Vice President of Research and Evaluation, Unite Us
LinkedIn: Halima Ahmadi-Montecalvo, PhD, MPH
LinkedIn: Unite Us

Improving health outcomes requires more than medical care alone—it demands a holistic approach that addresses Social Drivers of Health (SDOH), such as housing, food security, transportation and interpersonal safety. The evidence is clear: addressing these factors not only improves health but also generates significant cost savings as evidenced during a recent educational session at HIMSS 2025.

During the session, Jay Ludlam, JD, Deputy Secretary for North Carolina Medicaid—a division of the North Carolina Department of Health and Human Services (DHHS)—shared key lessons and outcomes from the state’s recent initiatives. These efforts led to reductions in inpatient and emergency department visits, along with $85 per member per month in cost savings. The program’s efforts demonstrate how addressing social needs can support two core health plan priorities: improving member health and reducing per-member costs.

The success of these initiatives relies heavily on strong community partnerships and the use of effective technology platforms. At HIMSS 2025, Ludlum highlighted how integrating community-based organizations with automated feedback loops to providers helps members receive the support they need. Below are outcomes and lessons learned from North Carolina Medicaid’s work.

North Carolina’s Healthy Opportunities Pilots (HOP)

North Carolina’s Medicaid program takes a pioneering approach: instead of simply paying for healthcare services, it invests in health itself. One of these investments is the organization’s Healthy Opportunities Pilots (HOP).

HOP is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions to high-needs Medicaid enrollees. The federal government authorized up to $650 million in federal and state Medicaid funding for HOP to operate in three regions of North Carolina over a five-year period using a phased-services launch.

Starting with a food insecurity pilot in 2022, Prepaid Health Plans (PHPs) pay for federally approved, evidence-based services, which are delivered by existing social services providers called Human Service Organizations (HSOs). At a high level, each participating organization is responsible for the following.

Prepaid Health Plans (PHPs): Approve member eligibility, authorize services, provide care management to members, check individuals enrolled and manage a pilot budget.

Care Managers: Interface with members, conduct community-based care management, assess beneficiary eligibility and track member progress.

Lead Pilot Entities (LPEs): Develop, manage and oversee a network of HSOs, provide technical assistance to HSOs, share best practices, collect and report data.

HSOs: Frontline social service providers that contract with the LPE to deliver services to members, submit invoices and receive reimbursement for services delivered.

This structured partnership model uses an advanced technology platform from Unite Us to enable providers to send secure electronic referrals, track their clients’ social journeys and use communication tools for care coordination, all without leaving the Unite Us platform.

A two-year interim evaluation was conducted by a third-party evaluator and found the following outcomes across 40,000 individuals and 900,000 nonmedical services.

• Inpatient admissions have decreased with six fewer hospital visits per month (72 per year) per 1,000 beneficiaries.
• The program generates an average savings of $85 per enrollee per month—equating to more than $1,000 per person annually.
• 96% of invoices for services are accepted and paid.
• $177M has been reimbursed to HSOs throughout the North Carolina community for providing eligible, non-medical interventions across food, housing, transportation, toxic stress and interpersonal violence (IFV) services since 2022. The most recent outcomes are available online.

Lessons Learned in Cross-Sector Collaboration

The findings speak for themselves and support ongoing investment in HOP. Here are four specific lessons learned across the North Carolina program.

• Technology is essential. Platforms help streamline services, track referrals and measure effectiveness. They also improve communication between providers, programs and members.
• Flexibility is key. Programs must evolve with community needs.
• Community involvement is necessary. Programs must be designed with input from local non-profits and service organizations.
• Dedicated leadership matters. Having team members focused on managing both technology and community partnerships increases effectiveness.

Technology Supports the Future of SDOH Programs

While community partnerships form the backbone of SDOH initiatives, technology is the nervous system that keeps everything running smoothly. Platforms like Unite Us provide a digital infrastructure that allows healthcare providers, government agencies and social services to collaborate efficiently. Here are five specific technological capabilities necessary to achieve similar SDOH program outcomes.

Data-driven insights: Analyze aggregate data across stakeholders to identify gaps.

Electronic referrals: Securely connect individuals to care coordinators and community resources for assistance in housing, food, transportation, utilities and more.

Track social journeys: Provide real-time dashboards and analytics to inform providers and care coordinators about the clients they serve.

Facilitate reimbursement: Automate payments between health plans and community organizations delivering covered services.

Digitize communications: Integrate communication tools so that interventions are timely, targeted and impactful.

Build SDOH Partnerships with a Purpose

As seen in this North Carolina initiative, investing in local collaboration and digital tools leads to measurable improvements in health and financial savings. Looking ahead, health plans should continue to prioritize whole-person care, integrating technology into their SDOH programs and remaining flexible to meet changing local needs.

With the right mix of partnerships, technology, and policy support, SDOH initiatives can drive lasting health improvements while controlling costs—demonstrating that healthcare isn’t just about medicine, but about the conditions that shape our lives.