Below are questions that the CommunityCares team regularly receives. Please take a moment to review the questions and answers. If you have additional questions, please email communitycares@contexture.org.

The CommunityCares Program

CommunityCares is a free, state-sponsored tool that helps healthcare providers and community-based organizations (CBOs) screen and refer members for social determinants of health (SDOH), also known as health-related social needs (HRSN). As Arizona’s only state-sponsored SDOH Closed-Loop Referral System (CLRS), CommunityCares offers organizations tools to screen for social needs using standard or custom assessments, send and receive electronic referrals with real-time updates, and access a statewide resource directory powered by 2-1-1 Solari Crisis and Human Services. Organizations also gain access to data tracking, analytics, and outcome measures, helping them better coordinate care and measure impact across communities.

Powered by Unite Us, CommunityCares connects providers across sectors to identify and address non-medical needs. Users can capture member consent, administer social screeners, and coordinate referrals to community-based resources. Providers receive updates throughout a member’s care journey and can track outcomes directly on the platform.

Organizations based in or serving Arizona that meet eligibility criteria can access the CommunityCares network at no cost or a subsidized rate. Eligible groups include:

  • Healthcare providers and health plans
  • Accountable care organizations
  • Clinically integrated networks
  • Public health authorities
  • State governmental agencies or bodies with a healthcare focus in Arizona
  • Local and county health departments
  • Schools (public and private)
  • Community-based organizations
  • Tribal providers or public health entities

Resources Available to Members through CommunityCares

Service Types:

  • Benefits Navigation
  • Clothing and Household Goods
  • Education
  • Employment
  • Entrepreneurship
  • Food Assistance
  • Housing and Shelter
  • Income Support
  • Individual and Family Support
  • Legal
  • Mental/Behavioral Health
  • Money Management
  • Physical Health
  • Social Enrichment
  • Spiritual Enrichment
  • Sports and Recreation
  • Substance Use
  • Transportation
  • Utilities
  • Wellness

Privacy & Security

The Unite Us platform is HITRUST-, SOC 2 Type 2-, and NIST-certified.

Yes. The Unite Us platform is fully HIPAA compliant and adheres to strict federal and state privacy regulations, including 42 CFR Part 2, FERPA, VAWA, and the CCPA.

Consent is required before sending a referral to another organization. Unite Us prompts users to obtain consent before initiating the referral process. The client must acknowledge that their data will be securely stored and shared to support coordination of services. This is a one-time, consent, recorded in the client’s profile. Expiration of Unite Us consent is event-driven and is not time limited. Consent can be captured: digitally, on paper, verbally, through user attestation. Digital Consent can be sent in 54 different languages.

Consent is required for sending referrals through the platform. If a client declines to give consent, providers can still share resource information directly via text, email, or print. Clients may be reminded that consent can be revoked at any time and that their data is securely stored.

Fiscal Incentives to use CommunityCares

CommunityCares is generally available for use at no cost to healthcare providers and CBOs in Arizona. Contexture has contracted with Unite Us to purchase and distribute licenses for specific organizations, as well as local and state governmental bodies and agencies. Contexture charges no participation or service fees for use of the CommunityCares services at this time.

Organizations will have access to standard licenses and dashboards, which include:

  • Closed-loop referral functionality
  • Screenings and assessments
  • Statewide resource directory via 2-1-1 Solari Crisis and Human Services
  • Data Dashboards
  • Data export capabilities

Additional services, such as system integration, may incur additional costs.

In addition to helping Arizona Health Care Cost Containment System (AHCCCS) members address SDOH to improve their overall well-being, through state initiatives like the Differential Adjusted Payment (DAP) and Targeted Investment programs (TIP), providers may be eligible to receive financial incentives by utilizing CommunityCares to meet program requirements.

Providers interested in learning more can reach out to the following program emails: ahcccsdap@azahcccs.gov; targetedinvestments@azahcccs.gov

Onboarding Process for CommunityCares

As a first step, all organizations interested in joining CommunityCares are encouraged to attend a CommunityCares Information Session (CIS) to learn more about the CommunityCares program and see a platform demonstration. Attending a CIS also begins the contracting process.

Healthcare providers: After attending a CIS, an SDOH advisor will be assigned to your organizations to support onboarding and post go-live support. A completed CommunityCares Agreement (CCA) is required before onboarding can begin.

Onboarding Stages:
Stage 1: Introduction meeting with SDOH Advisor
Stage 2: Attend a Workflow and Configurations Meeting for system step-up as well as a Data and Insights Presentation to learn more about how to track your data. Optional: If considering an integration, a technical discovery meeting may also be scheduled at this stage.
Stage 3: Submit required documentation for platform configuration and attend New User Training.
Stage 4: Receive go-live notification and ongoing post-live support from your SDOH Advisor

Community-Based Organizations: After attending a CIS, a Community Program advisor will be assigned to your organizations to support onboarding and post go-live support. Prior to onboarding, CBOs can schedule office hours with the Contexture team to ask additional questions, see another platform demonstration, and discuss workflow. A completed CommunityCares Agreement (CCA) is required before onboarding can begin.

Onboarding Stages:
Stage 1: Complete CommunityCares Agreement
Stage 2: Submit required documentation for platform configuration by completing the Enhanced Onboarding Form. Attend a Workflow and Configurations meeting for system set-up.
Stage 3: Attend End User Training and Receive go-live notification.
Stage 4: Upon go-live a Community Program Advisor will be assigned to assist with ongoing post-live support and technical assistance.

Healthcare providers:

Less complex organizations (e.g. web-based portal, single location, limited number of users, etc.) = approximately 6-8 weeks.

More complex organizations (e.g. integrations, multi-system set-up, customized screening tools, large user group, etc.) = approximately 8-12 weeks for successful implementation.

CBO and (non-healthcare) Government Entities:

Less complex organizations (e.g. web-based portal, single location, limited number of users, etc.) = approximately 4-6 weeks.

More complex organizations (e.g. multi-system set-up, customized screening tools, large user group, etc.) = approximately 6-8 weeks for successful implementation.

Integration for Electronic Health Records or Electronic Care Management Systems

CommunityCares offers integration with several electronic health record systems, including Epic, Cerner, eClinicalWorks, Athena, Azara, NextGen, and Meditech. Additionally, CommunityCares now offers API integration options. These integrations streamline platform access, improve the user experience, and reduce duplicate data entry. Functionality may vary depending on the system. Interested organizations should contact their assigned Contexture SDOH Advisor for details or reach out to the SDOH Advisor team at communitycares@contexture.org.

Integration functionality is an additional service and does have an associated cost of $10,000 per year, per instance, for the participating organization. API integration costs depend on the type selected. To learn more reach out to your assigned advisor or communitycares@contexture.org.

CommunityCares Terminology

A record within the platform that documents the requested service(s) provided to a client. A case might include case notes, interactions with the client (such as phone calls, emails, or in-person meetings), services provided, assessments, or uploaded documents. A case represents a client’s need and their care journey to address that need in the platform.

A one-time record for delivering information about a person and the needs they have, from one user to another. Each referral is related to a client record.

Referrals can be sent and tracked regardless of whether the program being referred to is onboarded into the CommunityCares network.

Off-platform: A referral to an organization, provider, or program belonging to an organization or entity not onboarded into the CommunityCares network. An off-platform case refers to services provided by providers or by programs with a Receiving Off-Platform Referrals status.

Note: These do not support “closed-loop” referral tracking.

On-platform: An organization that is part of a coordinated CommunityCares network and connected through the Unite Us software, enabling closed-loop referral functionality.

A grouped referral allows referrals to be sent to multiple programs simultaneously, increasing the likelihood of timely connection to services. The first organization to accept the referral works with the client, while the remaining referrals are automatically recalled.

Providers and CBOs may offer multiple programs within their organization’s profile in the CommunityCares platform. An internal case is created when an organization serves a client directly within its own programs (i.e. refers a client from one of their programs to another, internally), without involving another organization through a referral.

CommunityCares Users

When a provider or CBO onboards, a staff person at every organization will be provisioned with an Oversight Administrator role. Any users with the Organization or Oversight Administrator user role have the ability to add and remove users directly in the platform. Organizations with system integrations or Security Assertion Markup Language Single Sign-On (SAML SSO) should coordinate with their assigned SDOH Advisor and use the Partner Registration Sheet (PRS) to add or remove users.

No, participating organizations should not create test clients within the production environment. If additional training is desired, or your organization would like access to a test environment, organizations should reach out to their assigned SDOH Advisor for training options.

CommunityCares Functionality

Performing a Social Determinants of Health(SDOH) Screening

While the platform includes tools such as PRAPARE to assess social needs, custom screeners can also be built into the platform based on provider or CBO preference. Regardless of the screening utilized, after completing the screening, the platform recommends referral pathways based on the client’s responses and securely stores screening data within the client facesheet. This article provides detailed instructions for conducting SDOH screenings. Platform license required to view.

Screening options include but are not limited to the PRAPARE and Accountable Health Communities (AHC) tools. Organizations can also utilize a custom screening tool at no additional cost.

No, providers are not required to use the SDOH screening tools available in CommunityCares. Providers have the flexibility to create and use a custom screening tool that better aligns with their patient population and clinic workflows. Alternatively, providers may choose to conduct screenings within their EHR and use CommunityCares for referrals only.

Note: for organizations participating in SDOH DAP, only screenings completed within CommunityCares will count toward monthly milestones.

Identifying Resources

CBO or government organizations can view referrals and cases only if directly involved in a client’s care within the platform. Referrals involving sensitive services (e.g., substance use, HIV) or sent to sensitive organizations remain restricted to protect client privacy. This shared view, when appropriate, supports coordinated and comprehensive care.

The platform supports efficient service discovery through features like service-type filtering and user-level favorites. These tools streamline referral creation workflows. This article outlines the process. Platform license required to view.

Yes. The platform uses the client’s address and their identified need to surface the most geographically relevant services. The organization can also use its own address or city and state only to locate nearby resources if the client is displaced, or would prefer not to have their address recorded.

Services are prioritized based on proximity, identified need, and any selected filters. A smart keyword search is also available to find the most relevant resources. This article details how to use the Browse Resource feature. Platform license required to view.

Sending a Referral

After identifying the clients need, referrals are created from the plus sign or from the client’s Facesheet. The user selects the appropriate service type, locates a suitable provider organization, enters a referral description, and captures consent if not previously documented. This article outlines the referral creation process. Platform licenses required to view.

Referral best practices depend on whom the service is intended to benefit:

  • Direct benefit to the minor (e.g., clothing, education, counseling): The referral should be made under the minor’s record.
  • Direct benefit to the guardian (e.g., mental health services for the parent): The referral should be created in the guardian’s record.
  • Benefit to the household (e.g., housing, utility assistance): The referral should be tied to the guardian’s record.

Grouped referrals enable partners to cast a wide net by sending a single referral to several organizations. The first to accept becomes the service provider, ensuring quick client connection. This article provides step-by-step instructions for sending grouped referrals. Platform license required to view.

Any organization with at least one listed program in the Unite Us platform can generate internal cases. This article outlines the step-by-step process for internal case creation. Platform license required to view.

Facilitating Communication and Data Collection

The Unite Us platform itself allows for visibility into the client journey via the utilization of a single, secure, comprehensive person record. Additionally, providers receive both email and in-platform notifications regarding referral progress or pending actions. Secure messaging enables communication between organizations involved in shared client support.

Data Exports: Users with Oversight Admin or Org Admin user roles can export tabular data filtered by data type (e.g., referrals, clients) and date range, directly from the platform.

Insights: This dashboard-based tool provides up to three licenses per organization and displays de-identified metrics related to network performance and referral trends over time.

If you have additional data needs, please reach out to your SDOH Advisor at communitycares@contexture.org

Recalling Referrals

Any organization may recall a referral, commonly due to non-responsiveness from the receiving provider or if the client no longer needs the service. Recalled referrals can either be re-routed to another organization or closed.

Turning Off the Ability to Receive Referrals

Organizations can disable referral receiving at the program level at any time, and should be doing so, as appropriate. This is useful when a program has reached capacity, exhausted funds, or is temporarily unavailable. This article outlines how to disable referral receiving. Platform license required to view.

The platform will prevent the referral from being created if the target program has disabled referral receiving.

Managing Off-Platform or Out-of-Network Referrals

Yes, providers can send in or out of network resource details directly to members through the platform via text, email, or printed materials and can document and track off-platform or out-of-network referrals within the platform. This article explains the process in detail. Platform license required to view.

AHCCCS recommends using a variety of SDOH resources outside CommunityCares. These include establishing a Community Resource Guide, which should contain contact information for commonly needed SDOH referrals in your local area. Additionally, AHCCCS has published a Community Resource Map which contains basic information about where to find care for primary care, behavioral health, integrated care, heat relief resources, and CBOs that are able to assist with a variety of SDOH needs. To access this resource please visit: https://tip-qic-map.netlify.app/

Additional Resources and Contact Information

AHCCCS funds the CommunityCares program and provides strategic oversight and direction of the program to ensure it is meeting the community’s’ needs.

Contexture is the administrator of the CommunityCares program and is responsible for community outreach and engagement, contracting, onboarding and implementation, post-live support and technical assistance.

Unite Us provides the software and technology platform that supports the CommunityCares program.

To connect with AHCCCS’s Whole Person Care Initiative, you can email wpci@azahcccs.gov

To connect with Contexture, you can reach out to your assigned Advisor or communitycares@contexture.org

To connect with Unite Us, you can click on the chat bubble on the bottom right-hand side of the platform or you can email the team at arizona@uniteus.com

To connect with the Differential Adjusted Payment program, participants can email: ahcccsdap@azahcccs.gov

To connect with the Targeted Investment Program participant can email: targetedinvestments@azahcccs.gov

Organizations active on the platform can access learning materials by selecting the graduation cap or question mark icon in the top right corner of the screen. These icons link to articles, self-paced learning modules, and live webinars. Additionally, organizations should reach out to their assigned SDOH Advisor for support. If you’re unsure who your SDOH advisor is, please reach out to communitycares@contexture.org.

Organizations not yet live may attend a weekly Community Information Session to learn more.

Program Partners

Contexture
Solari
211az
UniteUs
Vitalyst
Garcia