A county health department, in collaboration with community-based organizations, conducts community listening sessions to identify priorities for health equity policies.

This tool can support health care and community-based organizations in building sustainable cross-sector partnerships.

A novel street psychiatry program offers essential mental health support to unsheltered individuals experiencing homelessness.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

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.

California leveraged Medicaid waiver authority to cover targeted pre-release services with the goal of improving the health of people reentering the community after incarceration.

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.

Partnerships between community-based organizations and primary care providers can improve depression care for older adults.

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.

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

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.

Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.

Lessons from Los Angeles County’s Housing for Health program to reduce homelessness.