Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients
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.
FINDINGS AND CONCLUSIONS:
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.
Overview and Methods
Common challenges and proposed solutions