Using community partnerships to integrate health and social services for high-need, high-cost patients

Issue: Our health care 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 health care delivery systems. Evidence on the experiences and outcomes of these programs is emerging, and there is much to learn about their approaches and challenges.

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

Methods: Mixed-methods approach, including literature search, surveys, semistructured 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 health care and social services providers; lack of expertise to integrate multiple data sources during health care or social services provision; and lack of a cross-sector workflow evidence base.