Sarasota Memorial Hospital, one of the largest public health systems in Florida, and Unite Us, one of the nation’s trusted technology partners for integrating health and community-based care, today released two evaluations demonstrating that connecting patients with community-based services through closed-loop referrals can remarkably reduce hospital readmissions. Specifically, the researchers highlighted:

  • A 17% reduction in 30-day all-cause readmission risk among those referred across the health system

  • A 59% reduction in the odds of postpartum-related and all-cause 30-day readmission for maternal patients insured by Medicaid

  • A 54% reduction in odds of 30-day readmissions for infants

  • A 22% reduction in 30-day all-cause readmission risk among patients under age 65

“These results demonstrate what’s possible when healthcare and community partners work together to address the social and practical barriers that affect health beyond the walls of our hospitals. Seeing meaningful reductions in readmissions across multiple patient populations reinforces the importance of delivering whole-person care,” said Mary O’Connor, manager of Community Health & Partnerships at Sarasota Memorial Hospital.

Read the full evaluations here:

Hospital-wide Evaluation Demonstrates Impact of Closed-Loop Referrals on Reducing Readmissions

Sarasota Memorial has spent the past several years strengthening processes to proactively address patients’ non-medical needs and connect them to community-based services. In partnership with community partners, the health system uses Unite Us’ closed-loop referral platform in the care delivery process across the health system, enabling clinicians to identify non-medical needs during inpatient stays, coordinate referrals to community organizations, and measure and track outcomes to confirm if patients receive the support they need after discharge.

A recent evaluation of Sarasota Memorial’s systemwide implementation of the closed-loop referral platform assesses how coordinated community referrals impact readmissions across inpatient populations. For patients referred to community resources during their inpatient stay, the study found a:

  • 17% reduction in 30-day all-cause readmission risk overall

  • 23% reduction in 30-day all-cause readmission risk among Medicaid patients

  • 22% reduction in 30-day all-cause readmission risk among patients under age 65

  • 20% reduction in 30-day all-cause readmission risk among low readmission-risk patients

“These results demonstrate that addressing patients’ non-medical needs isn’t just the right thing to do, it’s a proven strategy for improving health outcomes,” said Dr. Amanda Terry, Senior Director of Research & Evaluation at Unite Us. “They also show how technology, trusted community partnerships, and accountable care coordination can work together to improve outcomes for patients while strengthening care delivery.”

Success in Maternity Services Helped Shape Sarasota Memorial’s Systemwide Approach

The hospital-wide implementation followed the rollout of a smaller, more targeted maternity initiative within Sarasota Memorial’s Women & Children’s Department. The initiative used Unite Us’ closed-loop referral system to connect families to community resources addressing critical non-medical needs that often affect recovery and long-term health outcomes for families after discharge. It harnesses a strong network of community partners through First 1,000 Days Suncoast, a local initiative focused on improving outcomes during babies’ earliest and most critical years.

An evaluation of the maternity program, published in BMC, compared outcomes for maternal patients and infants connected to services through Unite Us after the 2020 implementation with patients and infants who received usual care before the referral system was adopted.

For maternal patients insured by Medicaid, the study found a:

  • 59% reduction in odds of postpartum-related and all-cause 30-day readmissions

  • 57% reduction in odds of all-cause hospital admissions up to three months postpartum

  • 55% reduction in odds of postpartum-related hospital admissions up to six months postpartum

For infants, the study found a:

  • 54% reduction in odds of 30-day readmissions

  • 43% reduction in odds of hospital admissions within the first three months of life

  • 46% reduction in odds of hospital admissions within the first six months of life

“This study is a testament to the power of connection and helps us achieve our collective vision for a supportive community that helps families provide a safe, stable, loving environment so that children are healthy, resilient, and can reach their dreams,” said Chelsea Arnold, DNP, APRN, Director for First 1,000 Days Suncoast.

Both studies add to a body of evidence that addressing non-medical needs that impact health through coordinated community partnerships can improve patient outcomes while creating measurable value for health systems.

About Sarasota Memorial Health Care System

Sarasota Memorial Health Care System is a regional medical center offering Southwest Florida’s greatest breadth and depth of care, with about 2,500 physicians and advanced practice providers, 11,000 employees and 2 million patient visits a year across its network of care. Sarasota County’s largest employer, the community-owned health system includes two full-service hospitals in Sarasota and Venice (and third under construction in North Port), freestanding ERs in North Port and Lakewood Ranch, a rehabilitation hospital, skilled nursing facility and comprehensive network of outpatient centers, urgent care clinics and First Physician Group primary and specialty care practices. Founded in 1925, SMH’s flagship Sarasota campus also is home to the Brian D. Jellison Cancer Institute, Cornell Behavioral Health Pavilion and Kolschowsky Research and Education Institute. In 2026, Sarasota Memorial was named one of the nation’s 15 Top Health Systems® by Modern Healthcare and Premier Inc., placing Sarasota Memorial among the highest-performing health systems in the United States. Both Sarasota Memorial Hospital-Sarasota and Sarasota Memorial Hospital-Venice have earned the highest 5-Star quality ratings from the U.S. Centers for Medicare & Medicaid Services (CMS), and SMH-Sarasota is the only Florida hospital – and one of just 11 in the nation – to earn a perfect 5-Star rating from CMS every year since the federal rating program began in 2016.

About Unite Us

Unite Us is the nation’s premier technology provider for integrating health and community-based care. Our proven product suite is used to proactively identify needs using advanced analytics, coordinate services between sectors in real-time, streamline referral and case management, and facilitate eligibility assessments and reimbursements across government, healthcare, health plans, and community organizations. The first of its kind, our closed-loop referral system prioritizes privacy and dignity and has integrated data and analytics tools used to measure impact, optimize programs, and shape policy. With over 2.1M services, we host the nation’s largest network of community-based health and economic services dedicated to improving whole-person health. Learn more at UniteUs.com and LinkedIn.

About First 1,000 Days Suncoast

First 1,000 Days Suncoast is a tri-county initiative comprised of 90 partner organizations supporting families and babies by connecting them with resources and tools through a large and comprehensive network. Sarasota Memorial Hospital was designated as the backbone organization, hiring a team to lead the operations and strategy. Through collaboration with community professionals and parents, the initiative identifies the most pervasive barriers to care for families and develops innovative solutions. The initiative was launched by the Charles & Margery Barancik Foundation, with continuing support from Sarasota Memorial Healthcare Foundation and other local donors. To spread awareness about the initiative and its services, parents and professionals can access First1000DaysSuncoast.org.

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