Many older adults have complex health problems that are exacerbated by non-medical problems such as unsafe housing, poor nutrition, lack of transportation, and isolation. Increasingly, health care providers are trying to address these social issues in addition to treating medical conditions. Commonwealth Fund–supported researchers explored how providers coordinate with local social services organizations and identified attributes common to “high-performing communities” where older adults’ health care use and costs are comparatively low.


Based on their interview findings, the research team identified four main factors common to high-performing communities:

  1. Health care and social services organizations regularly work together to identify challenges faced by older adults and to coordinate solutions to these challenges. Alternatively, in low-performing communities — those with high rates of care utilization and costs — health care providers struggle to coordinate with social service organizations.
  2. Hospitals are more likely to participate in partnerships addressing issues such as community planning, housing, cross-agency coordination, and post-hospitalization case management. Low-performing communities do not have well-established partnerships.
  3. There are strong norms encouraging collaborative problem-solving, along with influential local political organizations and financially stable hospitals.
  4. Older adults often have high levels of both financial support and support from families and religious organizations.