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Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients

Integrating health and social services for high need high cost patients using community partnerships
  • Community-based partnerships around the U.S. are seeking to integrate health and social services for complex patients

  • Programs that link health care providers with local social service organizations share a number of challenges, including financial sustainability

  • Community-based partnerships around the U.S. are seeking to integrate health and social services for complex patients

  • Programs that link health care providers with local social service organizations share a number of challenges, including financial sustainability


  • Issue: Our health care and social services delivery systems are not well-equipped to effectively manage patients with multiple chronic diseases and complex social needs such as food, housing, or substance abuse services. Community-level efforts have emerged across the nation to integrate the activities of disparate social service organizations with local health care delivery systems. Evidence on the experiences and outcomes of these programs is emerging, and there is much to learn about their approaches and challenges.
  • Goal: Profile and classify burgeoning initiatives, understand common challenges, and surface solutions to address those challenges.
  • Methods: Mixed-methods approach, including literature search, surveys, semistructured interviews with program leaders, and consultation with expert panels.
  • Findings and Conclusions: We categorized cross-sector community partnerships in four dimensions. We also identified five common challenges: inadequate strategies to sustain cost-savings, improvement, and funding; lack of accurate and timely measurement of return on investment; lack of mechanisms to share potential savings between health care and social services providers; lack of expertise to integrate multiple data sources during health care or social services provision; and lack of a cross-sector workflow evidence base.


Effectively managing patients with complex clinical and social needs requires thoughtful integration of health care and social services.1 Research has shown that patients with multiple clinical and social needs consume a large share of health care services. Social services providers, though historically disconnected from the broader health system, play an important role in providing services for these patients.2

Recognizing the opportunity to better address health-related social needs, communities across the United States have begun experimenting with programs to connect health care providers with community-based organizations (CBOs) that address social needs. These needs include housing and food insecurity and assistance with utilities and transportation, among other issues.3 These programs have been accelerated as a result of top-down reforms initiated by federal policy and demonstration projects and bottom-up innovations driven by community-led efforts.

In this brief, we survey the landscape of these programs, highlight common challenges, and propose solutions, using a mixed-methods approach that includes a literature search, interviews, and survey of selected programs. (See How We Conducted This Study.)

Key Findings, Challenges, and Proposed Solutions

We identified 301 cross-sector community partnerships across the country that met our criteria. Of these, we evaluated 64, using web surveys and in-depth interviews. We evaluated the relative advances of these programs in the four dimensions according to our framework (Exhibit 1, Appendix 4):

  • coordination
  • financial alignment
  • data- and information-sharing
  • metric reporting.



Based on results of cluster analysis of the survey and interview results, we identified significant variations among the programs in these four dimensions. Differences notwithstanding, all cross-sector community partnerships share many common features and face common challenges. Much emphasis was placed on including social services and nontraditional types of care and services in addressing the needs of at-risk patients and forming community partnerships. Most programs include participants from a diverse set of CBOs and a sizable minority (21.5%) includes some risk-sharing mechanism among participating organizations (Exhibit 2).



Another important theme that emerged was using hospital utilization measures (e.g., emergency department use, preventable hospital admissions and readmissions, excess hospital stays) to assess program performance. A smaller set of organizations used other measures, like prescription drug use and high-cost imaging. Looking forward, organizations hoped to focus on patient outcomes and population-level indicators. Among the most referenced theme in our study was the importance of integrated information technology, as well as the challenges in using such tools and improvements needed across technology platforms. All the organizations cited using IT in program operations, but most noted challenges and room for improvement within existing technology. We identified five common challenges that these programs face (Exhibit 3).



Implications and Conclusion


Our findings suggest that there is an emerging and diverse group of programs formally coordinating services between independent health care and social service organizations. These programs differ in significant ways but have common challenges. In addition to proposing specific solutions (Exhibit 3), we developed a community playbook to address these challenges and to assist communities as they work to forge cross-sector partnerships.

To implement solutions, federal and local policymakers, philanthropic agencies and foundations, and local anchor hospitals must continue to provide support, funding, and expertise. For example, systemwide payment reforms around transitional care activities and population health are critical to sustain innovation, to facilitate peer learning, and to ultimately integrate successful elements of these innovations into policy and systemwide practices. Toward this end, the Center for Medicare and Medicaid Innovation has launched the Accountable Health Communities program.4

Our findings highlight the key role that payment reforms play in building a more integrated health care and social delivery system for complex patients. While there is broad agreement on the need for payment reform that replaces the current fee-for-service system, there is no consensus on the most appropriate payment model or how to move away from our current system.5 Interviewees cited challenges including the lack of flexible payment models to properly incentivize and engage social services providers and the difficulty in sustaining programs beyond the initial funding period. At the same time, there is a wide diversity of the payment models powering the programs in our study and little agreement among the interviewees on what types of financial arrangements are needed.

Establishing an evidence base for cross-sector partnership will require continued funding and experimentation, as well as additional collaborative projects, learning networks, and information clearinghouses to disseminate the significant but often isolated work occurring across the country.


How We Conducted This Study

For this study, we used a mixed-methods approach. First, an extensive literature search, semistructured interviews, and email surveys of key informants (including community leaders, academic experts, national thought leaders, and policymakers) allowed us to identify a robust list of cross-sector community partnerships across the country. This also allowed us to produce a rubric, or framework, to assess the relative advances of a community effort, using four dimensions. After these steps, we focused on programs that target socially vulnerable, high-utilization, or medically complex populations, and which also demonstrate at least one of the following:

  • formal financial arrangement between two or more distinct organizations or units within an organization in the health services sector that share similar funding streams and client delivery goals
  • care coordination between the clinical sector and another sector
  • risk-sharing among organizations outside the clinical sector.

We subsequently performed quantitative surveys of these programs and semistructured, in-depth interviews with key personnel from a stratified purposive sample of programs. After establishing the key challenges of these programs, we consulted with national experts and drew from our own local efforts to propose solutions to problems identified and to establish a playbook for communities to use going forward. For a more detailed description of the methods, see Appendix 1.



1 S. S. Wallack and C. P. Tompkins, “Realigning Incentives in Fee-for-Service Medicare,” Health Affairs, July/Aug. 2003 22(4):59–70; K. Minich-Pourshadi, Gainsharing, Shared Savings Examined (HealthLeaders Media, Aug. 2012); A. J. Demetriou and J. A. Patterson, Jr., “ACO — Legal Structure, Governance, and Leadership,” ABA Health eSource (American Bar Association Health Law Section, April 2011); and ACO Update: Accountable Care at a Tipping Point (Oliver Wyman, April 2014).

2 L. A. Chwastiak, D. S. Davydow, C. L. McKibbin et al., “The Impact of Serious Mental Illness on the Risk of Rehospitalization Among Patients with Diabetes,” Psychosomatics, March/April 2014 55(2):134–43; M. Rowland, J. Peterson-Besse, K. Dobbertin et al., “Health Outcome Disparities Among Subgroups of People with Disabilities: A Scoping Review,” Disability and Health Journal, April 2014 7(2):136–50; E. K. Fry-Bowers, S. Maliski, M. A. Lewis et al., “The Association of Health Literacy, Social Support, Self-Efficacy and Interpersonal Interactions with Health Care Providers in Low-Income Latina Mothers,” Journal of Pediatric Nursing, July/Aug. 2014 29(4):309–20; and E. L. Schiefelbein, J. A. Olson, and J. D. Moxham, “Patterns of Health Care Utilization Among Vulnerable Populations in Central Texas Using Data from a Regional Health Information Exchange,” Journal of Health Care for the Poor and Underserved, Feb. 2014 25(1):37–51.

3 Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation: Report to Congress (CMS, Dec. 2014); and Centers for Medicare and Medicaid Services, Accountable Health Communities Model (CMS, n.d.).

4 Centers for Medicare and Medicaid Services, Accountable Health Communities Model (CMS, n.d.).

5 E. F. Taylor, T. Lake, J. Nysenbaum et al., Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms, White Paper 11-0064 (Agency for Healthcare Research and Quality, June 2011).


The authors are grateful to the Commonwealth Fund for support for this work. They also recognize the valuable information provided in interviews by the Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation, National Association of Medicaid Directors, Pennsylvania Department of Human Services, Oregon Health Authority, California Department of Health Care Services, America’s Essential Hospitals, Association for Community Affiliated Plans, Bazelon Center for Mental Health Law, Legal Services of Eastern Missouri, and Western Center on Law & Poverty.


Publication Details



Bin Xie, Director of Health Services Research, Parkland Center for Clinical Innovation

[email protected]


R. Amarasingham, B. Xie, A. Karam et al., Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients, The Commonwealth Fund, January 2018.