Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations

Recognizing that social factors influence patient health outcomes and utilization, health systems have developed interventions to address patients' social needs. Care coordination across the health care and social service sectors is a distinct and important strategy to address social determinants of health, but limited information exists about how care coordination operates in this context. To address this gap, the authors conducted a systematic review of peer-reviewed publications that document the coordination of health care and social services in the United States. After a structured elimination process, 25 publications of 19 programs were synthesized to identify patterns in care coordination implementation. Results indicate that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services. Publications discussing these programs often provide limited detail on other key elements of care coordination, especially the nature of referrals and care coordinator caseload. Additional research is needed to document critical elements of program implementation and to evaluate program impacts.