Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients

In order to better address health-related social needs, communities across the country have been experimenting with programs to connect health care providers with community-based organizations (CBOs) that address social needs, such as housing, food insecurity, and assistance with utilities and transportation.

This brief from the Commonwealth Fund surveys the landscape of these programs, highlights common challenges, and proposes solutions.

Some of the key takeaways are:

  • Programs in communities across the nation are coordinating services between health care providers and social service organizations to help patients with housing, food insecurity, transportation, and other issues.
  • These programs share challenges related to financial sustainability, measurement of health outcomes and cost-savings, and integrated information technology.
  • Consensus is needed on the most appropriate payment models and ways to move away from fee-for-service