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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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 OpinionWhat does this mean?