Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.
Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.
Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.
A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.