Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients

Amarasingham R, Xie B, Karam A, Nguyen N, Kapoor B
Publication Year: 2018
Patient Need Addressed: Behavioral health, Chronic Conditions, Substance Use
Intervention Type: Partnership
Study Design: Mixed-Methods
Type of Literature: Grey

Our healthcare and social services delivery systems are not well-equipped to effectively manage patients with multiple chronic diseases and complex social needs such as food, housing, or substance abuse services. Community-level efforts have emerged across the nation to integrate the activities of disparate social service organizations with local healthcare delivery systems. Evidence on the experiences and outcomes of these programs is emerging, and there is much to learn about their approaches and challenges.

Profile and classify burgeoning initiatives, understand common challenges, and surface solutions to address those challenges.

Mixed-methods approach, including literature search, surveys, semi structured interviews with program leaders, and consultation with expert panels.

We categorized cross-sector community partnerships in four dimensions. We also identified five common challenges: inadequate strategies to sustain cost-savings, improvement, and funding; lack of accurate and timely measurement of return on investment; lack of mechanisms to share potential savings between healthcare and social services providers; lack of expertise to integrate multiple data sources during healthcare or social services provision; and lack of a cross-sector workflow evidence base.

Insights Results

Overview and Methods

  • Authors took mixed-methods approach (i.e., literature search, surveys, semi-structured interviews with program leaders, consultation with panel experts) to profile and classify initiatives, challenges, and solutions to community-level efforts to integrate social service organizations with healthcare delivery systems


    • Authors identified 301 cross-sector community partnerships and evaluated 64 using web surveys and in-depth interviews. Authors evaluated partnerships on 4 criteria: 1) Coordination; 2) Financial alignment; 3)Data and information sharing; and 4)Metric reporting
      Common challenges and proposed solutions
    • Sustainability: Many programs are grant-funded and may not be sustainable after funding is complete. Suggest payment reform around transitional care activities and population health; coalition of CBOs establishing alignment with hospitals’ strategic plans
    • Measuring outcomes: Many programs lack infrastructure and know-how to define and measure most relevant outcomes and accurately estimate cost-savings. Authors suggest establishing common data dictionary across hospitals, health systems, and community-organizations
    • Shared savings: Limited mechanisms and knowledge of how to share savings. Suggest identification of local philanthropies, foundations, and trusts that would provide funding to accelerate experimentation around financial partnerships; focus on areas where health systems are subject to potential financial penalties or incentives
    • Data and technology enterprise: Many community based organizations lack a technical platform, infrastructure, and know-how to integrate data from different sources such as EMRs and claims data. Suggests utilization of workflow management systems at the CBO-level that could integrate with EMR systems; use of hospital data and technology enterprise to serve as anchors for community efforts
    • Cross-sector workflow evidence base: Programs struggle to define cross-sector, multiorganization, clinical, and social workflows. Suggests demonstration grants provide critical support to experiment and establish this evidence base; national collaboratives; learning networks, and information clearinghouses can also help full gap
    • Findings also highlight the key role payment reforms play in building a more integrated health care and social delivery system for complex patients. Interviewees had little agreement on the types of financial arrangements needed