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.