- 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):
- 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.