Referral System to Address Social Determinants of Health (SDOH) Needs in Arizona

Contexture, Arizona’s health information exchange, teamed with the Arizona Health Care Cost Containment System (AHCCCS), and, in collaboration with 2-1-1 Arizona and Solari Crisis & Human Services, implemented a single, statewide referral system, CommunityCares, to address social determinants of health (SDOH) needs in Arizona.

This new technology platform, powered by Unite Us, is designed to connect healthcare and community service providers to streamline the referral process, foster easier access to vital services and provide confirmation when social services are delivered.

Get Started Today – Contact the CommunityCares Team

Program Partners

Program Genesis

AHCCCS, Arizona’s state Medicaid agency, launched its Whole Person Care Initiative (WPCI) to focus on the social factors that have an impact on individual health and well-being, such as housing, employment, criminal justice, non-emergency transportation, and home and community-based
services interventions.

As part of the WPCI strategy, AHCCCS partnered with Contexture to develop a technology solution that can support providers, health plans, community-based organizations (CBOs) and community stakeholders in meeting the healthcare and social-economic needs of Arizonans.

By combining the forces of the Arizona HIE, AHCCCS and 2-1-1 Arizona, operated by Solari Crisis & Human Services, and leveraging the power of technology, the Unite Us platform promises to be a game changer in helping the community better serve the social service needs of all Arizonans.

What are Social Determinants of Health?

Social determinants of health are the conditions in the environments where people are born, grow, live, learn, work, play and age that affect a
wide range of health, well-being, functioning, and quality-of-life outcomes and risks.

Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of such resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency and health services, and environments free of
life-threatening toxins.

Program Goals

  • Care coordination
  • Connecting our communities

  • Improving health outcomes with a whole-person care mindset
  • Data-driven approach

CommunityCares System Features

  • Closed-loop referrals with outcome tracking
  • No wrong door: easily connect clients to resources across the state in one platform

  • Screenings and assessments for identifying client needs

  • Alerts and communications about client case progress

  • Data dashboards, analytics and outcomes

  • Resource directory

Advantages to Community-based Organizations

As organizations aimed at making desired improvements to a community’s social health, well-being and overall functioning, CBOs are
instrumental in providing necessary services to support those in need.

CommunityCares provides myriad benefits designed to enhance care coordination and, ultimately, help better meet the needs of the
organization and people it serves, such as:

  • Keep track of the people you’re helping.
  • Access a reliable and up-to-date resource directory.
  • Update your organization’s information, including turning on/off receiving electronic referrals..

  • View and pull data on your organization’s activity.

CommunityCares CBO Incentive Program

New financial incentive program allows CBOs to earn up to $10,000 for joining CommunityCares.

To facilitate adoption of the CommnityCares SDOH referral system, CBOs are now eligible to receive financial incentives when participation
milestones in the CommunityCares program are achieved.

Participation milestones:

  • Milestone 1: $2,000 = Sign CommunityCares Access Agreement, go live on the CommunityCares SDOH system and opt-in to receive
    referrals for at least one (1) service. User login and training required.
  • Milestone 2: $3,000 = Meet usage metric: Respond to 75% of referrals within two (2) business days for six (6) total months.
  • Milestone 3: $5,000 = Meet usage metric: Respond to 75% of referrals within two (2) business days for 12 total months.
Learn How to Participate Here

CommunityCares SDOH System Roadshow Series

We hosted a series of community education events to showcase the new platform driving CommunityCares, Arizona’s SDOH referral system during the month of August 2022.

Attendees were treated to a demo of the new system and learned how to participate in
the program.

Each presentation featured:

  • A brief overview of the SDOH program.
  • A demonstration of the new CommunityCares technology solution powered by Unite Us.
  • A brief highlight of the Arizona Healthcare Directives Registry (AzHDR).
  • Q&A forum.

To view or download a copy of the slide presentation, click here.

CommunityCares SDOH System Roadshow Series

We host a series of community education events to showcase the CommunityCares platform driving Arizona’s SDOH referral system.

Our virtual CommunityCares SDOH Roadshow presentations are held weekly on Thursdays. Guests will enjoy exploring the new system and learn how to participate in the program.

Each presentation features:

  • A brief overview of the SDOH program.
  • A demonstration of the new CommunityCares platform solution powered by Unite Us.
  • A brief highlight of the Arizona Healthcare Directives Registry (AzHDR) .
  • Q&A forum.

Click here to view the event schedule and register to attend a session.

You’re invited to attend, so register today!

Other links of interest:

  • Watch a video of the presentation.
  • View or download a copy of the slide presentation.
  • Read Frequently Asked Questions (FAQ).

The Journey Thus Far…

Organizations live on the CommunityCares system:

AHCCCS SDOH Presentation

We invite you to watch the video archive of AHCCCS Director Jami Snyder’s presentation on the role of the SDOH referral system in the state’s Whole Person Care Initiative, delivered at ACHIEVE 2020, the Health Current Annual Summit & Trade Show.

The Journey Thus Far

Organizations live on the CommunityCares platform:

Arizona SDOH Workgroup

The Arizona Social Determinants of Health (SDOH) Workgroup, convened in conjunction with AHCCCS’ Whole Person Care Initiative, was established in 2020 and consisted of some 40 organizations from across the state that came together to provide both a healthcare and a service community perspective to help research, define, procure and implement Arizona’s future SDOH referral system. The workgroup was formally discontinued with the launch of CommunityCares in 2021. A special thanks to the organizations listed below for their participation in the Arizona SDOH Workgroup.

  • A New Leaf


  • Arizona Council of Human Services Providers

  • Arizona Healthy Communities
  • Arizona Hospital & Healthcare Association
  • Care1st Health Plan Arizona

  • Catholic Community Services – Yuma
  • CommonSpirit Health

  • Circle the City

  • Copa Health

  • Dignity Health

  • El Rio Health

  • First Things First

  • Garcia Family Foundation
  • HonorHealth Desert Mission Food Bank

  • Human Services Campus

  • Magellan Complete Care of Arizona

  • Mercy Care Plans

  • Native American Connections

  • Native Health

  • North Country HealthCare

  • Polara Health (formerly West Yavapai Guidance Clinic)

  • Solari Crisis & Human Services and 2-1-1 Arizona

  • Sonora Quest Laboratories

  • Southwest Behavioral & Health Services

  • St. Joseph the Worker

  • Sunset Health

  • Tucson Medical Center

  • UMOM New Day Centers
  • United Healthcare

  • Vitalyst Health Foundation

Media Center

News Releases

SDOH Referral System Technology Partner Announced

In the News

Healthcare Innovation News Article

Media Center

News Releases

Health Current Announces NowPow as the Technology Partner

News Releases

Healthcare Innovation News Article

Questions About CommunityCares?

Questions About CommunityCares?

Contact the CommunityCares team at

Visit the CommunityCares Arizona page on the Unite Us website.