Community care coordination systems: Connecting patients to community services

As states, communities, health systems and providers begin to address the social determinants of health, an essential element is a comprehensive system that connects patients with both the health and social service sectors so all needs are addressed. We refer to these as community care coordination systems. Patients with multiple health and social needs tendto be high users of health care services and incur high health care costs. These patients with multiple needs are often left on their own to navigate our fragmented systems. When medical and social service providers have a care coordination system to which they can refer patients for needed services, it offers an opportunity for communities to address social determinants of health needs more effectively and efficiently.