Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals

Melissa Sherry
Jennifer Wolff
Jeromie Ballreich
Eva DuGoff
Karen Davis
Gerard Anderson
Journal Article
March 2016

This study examined five programs that serve patients with complex needs through medical and non-medical services.

  • Authors created a framework to illustrate the foundational factors that encourage effective collaboration, including flexible financing, shared leadership, shared data, and a commitment to person-centered care.
  • The five programs represented diversity in geography and patient population, but all shared a commitment to person-centered care, namely through addressing social needs as well as medical needs.
  • In all of the programs, the health center served as the convening group among various services and the source of funds.
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Population Addressed
Adults Under 65 with Disabilities
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How are innovative programs bridging the silos between medical and non-medical services to better serve people with complex needs?
  • What are the attributes of these programs that facilitate collaboration across services and organizations?
Level of Evidence
What does this mean?