Insights from patient-level encounter histories can support optimizing care coordination team staffing for high-need patients.

Embedded peer navigators provide support and mentorship for people experiencing homelessness, leading to increases in chronic disease screening and referrals.

Curated collection of research studies highlights the efficacy of services provided by community-based organizations, with a focus on outcomes relevant to health care partners.

An overview of NYC Health + Hospital’s implementation of a primary care-based social needs screening and referral program, including key implementation challenges and success factors.

A program to connect Medicaid ACO enrollees with nutrition and housing-related services demonstrated early indications of effectiveness.

This webinar highlighted one successful CBO-health plan partnership model to explore why they entered into a partnership, how they put their contract into practice, and outcomes of the partnership so far.

Well-designed bidirectional community and referral pathways may help bridge the community-clinic divide.

Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Guide for hospitals to address housing instability by understanding the evidence, evaluating different approaches, and exploring case studies of health system-led programs.

Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.

Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Medicare Advantage plans report different barriers to partnering with community-based organizations, but there are strategies to develop effective partnerships.

Guidance on partnering with community-based organizations to provide services such as meal delivery and transportation for dually eligible individuals.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?