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

Commonwealth Fund
Publication year:
Place of publication:
New York

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. This briefing looks at programmes across the United States that have begun experimenting with programs to integrate health care providers with community-based organizations (CBOs) that address social needs. These needs include housing and food insecurity and assistance with utilities and transportation, among other issues. The briefing highlights common challenges, and proposes solutions, using a mixed-methods approach that includes a literature search, interviews, and survey of selected programs. The findings categorize cross-sector community partnerships in four dimensions: coordination, financial alignment, data and information sharing, and metric reporting. They 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. (Edited publisher abstract)

Subject terms:
integrated care, health care, complex needs, social services, social care, voluntary organisations, joint working;
Content type:
United States
Register/Log in to view this resource

Key to icons

  • Free resource Free resource
  • Journal article Journal article
  • Book Book
  • Digital media Digital media
  • Journal Journal

Give us your feedback

Social Care Online continues to be developed in response to user feedback.

Contact us with your comments and for any problems using the website.

Sign up/login for more

Register/login to access resource links, advanced search and email alerts