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

Ruben Amarasingham
Bin Xie
Albert Karam
Nam Nguyen
Bianca Kapoor
January 2018

Throughout the country, efforts are increasingly emerging to integrate social services into health care systems. This resource classifies new initiatives, identifies common challenges, and proposes solutions to address those challenges.

  • The authors evaluated 64 cross-sector community partnerships along four dimensions: coordination, financial alignment, data- and information-sharing, and metric reporting. 
  • Common challenges included inadequate strategies to sustain cost savings; lack of mechanisms to share savings between health care and social services providers; and lack of expertise to integrate multiple data sources.
  • Solutions include 1) payment reform around transitional care activities and 2) establishing a common data dictionary and data set requirements across hospitals, health systems, and community-based organizations.
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What kinds of initiatives are emerging to incorporate social services into health care?
  • What common challenges have surfaced, and what are some ways to address them?
Level of Evidence
Expert Opinion
What does this mean?