Individual Research Projects

About the Projects

Systems for Action (S4A) is a program of RWJF that aims to discover and apply new evidence about ways of aligning the delivery and financing systems that support a Culture of Health. Based at the University of Kentucky College of Public Health, S4A seeks to identify system-level strategies for enhancing the reach, quality, efficiency, and equity of services and supports that promote health and well-being on a population-wide basis.
Investigators are testing innovative ways of aligning the delivery and financing systems for multiple services, with a focus on the health and economic outcomes that result. Research findings will shape future directions in health and social policy while informing clinical and administrative practices used by the professionals that work in these diverse but inter-related sectors.













Housing for Health: Assessing the Cross-Sector Impacts of Providing Permanent Supportive Housing to Homeless High Utilizers of Health Care Services

Principal Investigators: Ricardo Basurto Davila, PhD, MS, Los Angeles County Department of Public Health & Corrin Buchanan, MPP, Los Angeles County Department of Health Services

Homeless individuals experience a higher risk for mortality, chronic illness and mental health disorders, and are often high utilizers of healthcare. The Housing for Health (HFH) initiative, created in 2012 by the Los Angeles County Department of Health Services (DHS), is designed to reduce homelessness and inappropriate use of expensive health care resources, and improve health outcomes for this vulnerable population. Homeless individuals who are high utilizers of medical services are referred to permanent supportive housing (PHS) and intensive case management services, and subsequently to benefits and services provided by agencies in multiple sectors, including substance use treatment services. To evaluate this novel mechanism for integrating the delivery and financing systems for housing, medical care, and public health services, the principal investigators are assessing the HFH cross-sector impacts and organizational and financing issues to explore:

  • the effectiveness of HFH and other housing models on client referrals to services for which they are eligible in the housing and other sectors;
  • the impact of HFH on housing performance indicators, service utilization, and costs across sectors;
  • whether linkages of HFH clients to other sectors create synergies, leading to system-wide improved outcomes and lower costs; and
  • whether HFH’s cross-sector impacts reduce health inequities by improving quality of care received and health outcomes among its most vulnerable clients.








The Impact of Integrating Behavioral Health with Temporary Assistance for Needy Families to Build a Culture of Health across Two-Generations

Principal Investigators: Mariana Chilton, PhD, MPH, and Sandra Bloom, MD, Drexel University Dornsife School of Public Health

The prolonged activation of stress response systems among children responding to adversity such as homelessness, hunger, or neglect, is a predictor of poor health and continued poverty among low-income families. To study the health and economic impacts and systems implications of integrated services provided by the Pennsylvania Department of Human Services and Drexel University’s Center for Hunger-Free Communities, the principal investigators are evaluating the Building Wealth and Health Network (The Network) intervention, designed to reduce health inequities by aligning Medicaid coverage for behavioral health services and Temporary Assistance for Needy Families (TANF) education and training services. This evaluation will:

  • assess the effects of trauma-informed peer support built into education and training on health and economic security for participants in the Network;
  • identify cost savings to both TANF and Medicaid to build a case for linking these service systems; and
  • engage low-income caregivers, state human services officials, and key decision-makers in identifying ways to improve support systems to promote a Culture of Health within anti-poverty programming.






Testing of a Community Complex Care Response Team to Improve Geriatric Public Health Outcomes

Principal Investigator: Carolyn E. Ziminski Pickering, PhD, MSN, BSN, RN, Michigan State University

Elder abuse and neglect (EA/N) is a public health and safety epidemic with impacts in emergency department utilization, nursing home placement, mortality, and financial losses. Vulnerability has been shown to be highly correlated with EA/N victimization, yet research is lacking on interventions aimed at decreasing vulnerability. The principal investigators of this study are reviewing the impact of a primary prevention strategy for EA/N victimization: the community complex care response team (CCRT) intervention. The CCRT intervention is a collaboration of three community agencies that provide 61 services across the medical care, public health and social and community services and support sectors and is evaluated by:

  • examining the impact of coordinated multi-sector service delivery offered by the CCCRT on two outcomes: EA/N and emergency department utilization;
  • exploring which institutions are best positioned to perform integrator roles in connecting vulnerable older adults to needed services and supports provided by the CCCRT, and
  • identifying implementation and translational issues of data sharing and storage across health and human service sectors.







Implementing a Culture of Health among Delaware's Probation Population

Principal Investigators: Daniel J. O’Connell, PhD, & Christine Visher, PhD
University of Delaware

Individuals under the U.S. probation system have higher incidences of health conditions including substance abuse and mental illness and are less likely to access health care and other social services, such as education, transportation, employment, and housing, than those not involved in the system. To investigate the process and impact of implementing a multi-agency “Culture of Health” team in the Delaware Department of Probation, the study combines the efforts of multiple agencies working across traditionally siloed systems, including the Departments of Health and Human Services, Labor, Housing, Education, and Correction. To evaluate this novel mechanism for integrating the delivery and financing systems for criminal justice probation services, medical care, employment, housing and other support services for justice-involved adults the principal investigators are:

  • testing the efficacy of using the Change Team approach to leverage different financing systems (e.g., Medicaid and private insurance) and service coordination (e.g., health care, education, and job training), and
  • providing education, screening, testing and referrals for  follow-up services to the probation population.






Community-Based Decision-making and Engagement with the Cheyenne River Sioux Tribe’s Public Health Plan: Weaving the Tasina Luta

Principal Investigators: Barbara Quiram, PhD, Professor, School of Public Health, and Director, Office of Special Programs & Global Health, Texas A&M University, and David Washburn, ScD, Assistant Professor, Health Policy and Management, School of Public Health Texas A&M University

Native American communities experience many obstacles to health and well-being due to adverse social, economic, and environmental conditions. Few tribal public health programs are financed adequately to surmount these obstacles. Fewer still are locally financed and managed. This study will elicit the values and preferences of Cheyenne River Sioux Tribe (CRST) members in order to enhance the implementation of the CRST’s first autonomous public health program, the Tasina Luta (Red Blanket). Through a series of focus groups and interviews with Tribal members and local service experts, this research will inform the efficient integration of the Tribe’s resources to better engage community members and achieve a larger collective impact.  This one-year developmental study will explore effective mechanisms for public health program diffusion within the CRST community, positioning the project for future quantitative work evaluating the impact of the identified implementation strategies.








Linking Education and Health Data to Improve Adolescent Health in Los Angeles

Principal Investigaors: Sheryl Kataoka, MD, MS, Professor, Psychiatry, University of Califrnia, Los Angeles Semel Institute, and Rebecca Dudovitz, MD, MS, Assistant Professor, Pediatrics, University of California, Los Angeles

Declines in academic performance often precede declines in health and health behaviors, particularly among minority youth living in economically distressed communities. The social and economic burdens imposed on communities with high rates of mental illness could be alleviated if patients were diagnosed and treated in adolescence rather than adulthood. Many adolescents with behavioral health needs fail to seek early treatment due to lack of access to care, finances, or knowledge of available resources. School performance may be a valuable early indicator of children in need of critical health services, particularly behavioral health services. Currently, the ability to use academic data as a population health and surveillance tool is limited by a poor understanding of which measures are the most meaningful indicators of behavioral health needs. This one-year developmental study will support the creation of a novel risk indicator tool that links academic performance and health data to identify academic indicators of such behavioral health needs as post-traumatic stress disorder, depression, and substance abuse. The research team will facilitate system alignment as they collaborate with leaders from the education, health, and social services sectors to design a tool that could be implemented within the school district. Findings will contribute to early prevention strategies and foster cross-sector collaborations between education and health providers to help improve adolescent behavioral health services equity in under-resourced communities.







Integrating Health and Social Services for Veterans by Empowering Family Caregivers

Principal Investigator: Megan Shepherd-Banigan, PhD, MPH, Research Health Scientist, Health Services Research and Development, Department of Veteran Affairs, and Assistant Professor, Population Health Sciences, Duke University

Injured war veterans face substantial barriers to maintaining employment, high levels of family strain, homelessness, and extensive unmet physical and mental health needs. The Department of Veterans Affairs (VA) offers a range of medical, public health, and social services to eligible veterans; however, these services reside within distinct bureaus leading to service fragmentation, poor alignment with veteran needs, and variability in access across medical centers. Federal funding was approved in 2010 to establish a national program to provide veterans’ caregivers with training on how to navigate the VA system, function as a care team member, and improve clinical skills. Evidence from the initial group of enrollees showed that veterans whose family caregivers participated in the program utilized more primary, specialty, and mental health services than did those whose caregivers did not participate. While use of health services increased, data regarding the influence of family caregivers on veterans’ use of social services is still needed. Using quantitative and qualitative methods, this one-year developmental study specifically investigates the effect of institutional support for family caregivers on veterans’ use of vocational rehabilitation and educational social services. Study findings will elucidate key contextual and scalable features of institutional support for family caregivers that can reduce system inefficiencies through improved services coordination.







Testing a New Terminology System for Health and Social Services Integration

Principal Investigators: Miriam Laugesen, PhD, Associate Professor, Department of Health Policy and Management, Columbia University Mailman School of Public Health, and Sara Abiola, PhD, JD, Assistant Professor, Department of Health Policy and Management, Columbia University Mailman School of Public Health

Current health care payment methods do not reflect the need for effective chronic disease prevention, nor do they address the social determinants of health. Historically, common payment standards intended to link private healthcare providers with payers did not factor in coding or language to cover services provided by nonmedical personnel. Nonmedical personnel, specifically those in the social services sector, remain at a financial disadvantage relative to their peers. Payment structures and coding systems are not neutral administrative directories but reflect the social and political environment in which they were produced. The inclusion or exclusion of covered services in the standard coding language has multiple downstream consequences and can lead to health inequities. This one-year developmental study will evaluate a novel mechanism for incorporating social services into existing health billing codes, thereby allowing both social and healthcare services to be reimbursed within one system. Review of regulations governing coding methodologies, insurance agency payer plans, and feedback from stakeholder interviews will inform recommendations on changes to policies that would codify social services and potentially improve access to services that address the social determinants of health.







Financing Integrated Health and Social Services for Populations with Mental Illness

Principal Investigators: Yuhua Bao, PhD, Associate Professor, Healthcare Policy & Research, Division of Health Policy and Economics, Associate Professor, Healthcare Policy & Research in Psychiatry, Weill Cornell Graduate School of Medical Sciences, and Lisa Dixon, MD, MPH, Professor, Psychiatry, New York State Psychiatric Institute / Columbia University Medical Center

Adolescents and young adults often experience their first episode of psychosis as they are preparing to enter high school, college, or the workforce. The long-term implications of neglecting a future generation’s mental health can range from an overburdened welfare system to overcrowding in correctional facilities. Implementing an intervention for first episode psychosis via Coordinated Specialty Care (CSC), the OnTrackNY program aims to help patients maximize recovery, improve social function, and manage their psychiatric symptoms. While coordinated care services are currently covered by public and private funding, little guidance is provided to payers on how to structure payments to CSC providers. This one-year developmental study will develop a flexible, multi-part payment system comprised of a bundled case-rate, a per-service, and a pay-for-outcome component. The resulting payment designs would then inform a decision support tool for payers of CSC and other multi-disciplinary, team-based interventions across the medical, social, and public health sectors. This project will address the barriers to adoption of payment innovations that can be accomplished by combining economics and health information technology to significantly improve population mental health.






Integrating Cross-Sectoral Health and Social Services for the Homeless

Principal Investigators: Jesus Valero, PhD, Assistant Professor, Political Science, University of Utah, and Hee Soun Jang, PhD, Associate Professor, Public Administration, Unviersity of North Texas

Members of the homeless population bear greater risk than other populations for many preventable diseases but are less likely to access healthcare systems. These individuals need to be engaged by multiple systems to access services and support related not only to stable housing but also to reliable transportation, employment opportunities, and a healthy family environment. This one-year developmental study will evaluate the US Department of Housing and Urban Development’s initiative, the Continuum of Care (CoC) system, which addresses homelessness through cross-sector collaboration. Specifically, investigators will use a mixed-methods approach to test whether CoCs that are under resource constraints in terms of funding availability, less than optimal diversity in their partner organizations, and poor quality partnerships, experience greater challenges in addressing the full spectrum of health needs of their homeless populations. The study will generate evidence of the degree to which coordinated community services and resources are effective in improving health and equity, and will capture the key factors in successful cross-sector collaborations for the homeless. Study findings will identify effective models of CoC networks and thereby advance knowledge on building a culture of health in communities with highly vulnerable homeless populations.






Optimizing Governmental Health and Social Spending Interactions

Principal Investigators: Beth Resnick, DrPH, MPH, Senior Scientist and Director, Office of Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health, and David Bishai, MD, MPH, PhD, Professor, Johns Hopkins Bloomberg School of Public Health

The United States spends more money on healthcare than other developed countries while experiencing significantly worse health outcomes, indicating a need to explore health drivers other than healthcare spending. While nonmedical barriers such as lack of adequate housing, education, and transportation are known to influence well-being, how spending that addresses these social needs affects health outcomes is less clear. This study will examine total government spending across both medical care and social service sectors to characterize the impact of such spending on health outcomes and disparities. The research team will create a novel longitudinal dataset that merges medical, public health, social services, and community service governmental spending with population health outcomes. Based on U.S. Census of State and Local Governmental Finance data, this new dataset will allow researchers to examine public spending across medical, public health, social and community service sectors at both the state and county levels. Study findings will engage cross-sector stakeholders in conversations about aligning public spending to achieve better health and reduce health disparities.






Testing a Shared Decision-making Model for Health and Social Service Delivery in East Harlem

Principal Investigators: Carl Letamendi, PhD, MBA, Director of Evaluation & Divisional Support, Center for Health Equity, New York City Department of Health and Mental Hygiene, and Jennifer Pierre, DrPH, MPH, Director of Qualitative Research, Center for Health Equity, New York City Department of Health and Mental Hygiene

Lack of coordination of health and community services with individual agencies working in isolation leads to wasted resources and poor outcomes for the most vulnerable in our nation’s neighborhoods. One method of addressing this lack of coordination is by adopting a place-based system integration model where providers of services collaborate and work together to improve the health and well-being of the populations they serve. This study will test this model that aligns a city health department with cross-sector community stakeholders to improve health and reduce inequities across neighborhoods. The research team will examine how the Center's shared decision-making model within the East Harlem Neighborhood Health Action Center; which encompasses the city health department, clinical and non-clinical partners, faith- and community-based organizations, and community health workers; will increase coordination, effectiveness, and efficiency across these sectors. Using qualitative & quantitative methods the research team will assess the community’s health outcomes, satisfaction, success in linking clients to needed services, and success in coordinating systems to improve health and health equity in the neighborhood. Lessons learned from this study will inform best practices for replicating this model in other neighborhoods in New York City and across the U.S.





Linking Medical Homes to Social Service Systems for Medicaid Populations

Pricipal Investigators: Sarah Hudson Scholle, DrPH, Vice President of Research, Quality Measurement and Research Group, National Committee for Quality Assurance, and Keri Christensen, MS, Director of Research Innovation, Quality Measurement and Research Group, National Committee for Quality Assurance

Low socioeconomic status and other social risk factors are linked to poor health outcomes and increased emergency department (ED) visits. Assessing and addressing these social risk factors can help improve these outcomes. However, connecting social services organizations addressing these risk factors with organizations providing medical services can be very challenging, due in part to systems that do not “talk” to each other. In this study, researchers will evaluate how implementing a web-based communication and care management platform supporting electronic communication between patient-centered medical homes and social service providers affects care for Medicaid patients. The research team will investigate the effects of the intervention on the identification and delivery of services to address social risks, quality of care, and unnecessary ED utilization. Findings from this study will contribute to best practices and guidance for other communities.



Strengthening the Carrying Capacity of Local Health and Social Service Agencies to Absorb Increased Hospital/Clinical Referrals

Principal Investigators: Danielle M. Varda, PhD, Associate Professor, School of Public Affairs, and Director, Center on Network Science, University of Colorado Denver, and Katie Edwards, MPA, Executive Director, The Nonprofit Centers Network

As hospitals and clinics increase screenings for social determinants of health (SDOH), referrals to agencies that provide services to address these needs also will increase. However, questions remain about the ability of nonprofits and other “community resources” to absorb these increased referrals for services. Using secondary data analysis, a review of existing capacity assessment models, and case studies of human service centers in Florida and Texas, researchers will develop and implement an approach for assessing the capacity of community social services organizations and their partners to absorb and meet the needs of referred clients. Findings will lead to improvements in understanding the nonprofit sector’s ability to respond to growing demand, ultimately contributing to the long-term goal of strengthening cross-sector partnerships and integration of services and systems to improve health outcomes.







Testing an Integrated Delivery and Financing System for Older Adults with Health and Social Needs

Principal Investigators: José Pagán, PhD, Professor, College of Global Public Health, and Chair, Department of Public Health Policy and Management, New York University, and Elisa Fisher, MPH, MSW, Deputy Director, Population Health and Health Reform, Center for Health Policy and Programs, New York Academy of Medicine

Addressing the social determinants of health is vital to improving individual and population health and advancing health equity. Research indicates that integrating health and social services is both necessary and cost-effective. This is especially true for the growing number of older adults who face increasing risk of multiple chronic health conditions, cognitive decline, and disability. The Community Care Connections program developed by Lifespan of Greater Rochester integrates care navigators and health care coordinators into the workflow and referral systems in health care delivery settings. These coordinators connect patients to resources, guide them across healthcare settings, and serve as their patient care advocates. The study utilizes a mixed-methods approach to assess the health, social, and economic impact of this program and examines these novel inter-organizational partnerships between social services and healthcare sectors. Project partners include New York University, The New York Academy of Medicine, Lifespan of Greater Rochester, the Rochester Regional Health Information Organization, and the University of Rochester Medical Center. The findings will help strengthen existing programs and provide important information about components critical for successful implementation.

Connecting Vulnerable Seniors to Nutrition Assistance Through a Managed Care Plan

Principal Investigators: Suzanne Kinsky, MPH, PhD, Adjust Assistant Professor, Behavioral and Community Health Sciences, University of Pittsburgh Medical Center and Alex Kalinowski, Benefits Data Trust

A vast majority of older Americans who are eligible for federal nutrition assistance programming remained unenrolled, placing them at increased risk of food insecurity and its associated adverse health conditions and healthcare costs. A research team led by Benefits Data Trust will study the health and economic effects of a novel health plan strategy to increase program enrollment. The University of Pittsburgh Medical Center Health Plan will access administrative data from Benefits Data Trust and the Pennsylvania Department of Human Services to determine which of their low-income Medicare members are eligible but not enrolled in the federal Supplemental Nutrition Assistance Program (SNAP), and proactively assist these members with enrollment. The team will use a randomized encouragement trial to determine the impact of this strategy on SNAP enrollment, health status, health care utilization and costs. Results will indicate whether there are strong clinical and economic reasons for the nation’s Medicare and Medicaid health plans to adopt programs that proactively assist their members with nutrition assistance enrollment.

Using Regional Governing Boards to Align Services for Rural Children of the Opioid Crisis

Principal Investigators: Alicia Bunger, PhD, Associate Professor, The Ohio State University

Children affected by the opioid epidemic need a complex array of services and supports to safeguard their health and wellbeing, including child protective services, legal representation, educational services, comprehensive physical and mental health care, and often foster care placement coupled with family reunification strategies. Timely access to these services is especially difficult in rural areas. A research team led by Ohio State University will test a strategy that uses regional, multi-sector governing boards to help organizations work together in coordinating services for children in rural areas. Using a combination of qualitative and quantitative methods, the team will examine the influence of regional boards on cross-agency communication, adherence to evidence-based guidelines, and attainment of key program goals including family reunification. The research team will work with the Public Children Services Association of Ohio, Ohio Association of County Behavioral Health Authorities, and Ohio Council of Behavioral Health and Family Service Providers to carry out the study.

Can Subsidized Transportation Options Slow Diabetes Progression?

Principal Investigators: Fei Li, PhD, Assistant Professor, Georgia State University Research Foundation and Christopher Kajeian

Populations with diabetes can successfully manage their condition if they have regular access to primary care along with access to quality food, physical, and social environments that support healthy lifestyles. Lack of safe, convenient, and affordable transportation options can make it difficult for low-income populations to access these resources. A research team led by Georgia State University will use a randomized trial to test several low-cost ways of improving transportation opportunities for low-income urban diabetic patients, including providing public transit vouchers, ride-share credits on Uber or Lyft, a cash benefit, or mobility counseling compared with usual medical care alone. The team will estimate the impact of these mobility enhancements on access to care, diabetes progression, healthcare utilization and costs. The research team will collaborate with Grady Health System, the Metropolitan Atlanta Rapid Transit Authority, the Atlanta Regional Commission, and the Atlanta Regional Collaborative for Health Improvement to conduct the study.

Financing Coordinated Medical and Social Services for Patients with Psychosis

Principal Investigators: Yuhua Bao, PhD, Associate Professor, Weill Medical College, Cornell University

For many mental health conditions, effective programs to restore health and social functioning require collaborative efforts that go far beyond the healthcare sector.  Individuals who are newly diagnosed with psychosis often require a carefully coordinated mix of specialty services including pharmacotherapy, behavioral counselling, educational services, vocational supports, and supportive housing options. Despite the existence of mental health parity laws, public and private health insurance plans often do not cover the full array of services required by patients, creating gaps and delays in care. This study will develop and test a decision support tool designed to help health plans and service providers estimate the total costs of care and implement integrated payment strategies for health and social services needed by patients newly diagnosed with psychosis. A research team led by Weill Cornell Medical College will collaborate with the New York State Psychiatric Institute, the New York Department of Health, and the New York Academy of Medicine to conduct the study. The resulting decision tool will be hosted on an online platform to inform financial planning and payment policies among health plans, Medicaid agencies, providers and service agencies nationally.

Addressing the Health and Social Needs of Justice-Involved Young Adults

Principal Investigator: George Naufal, PhD, Assistant Research Scientist, Public Policy Research Institute, Texas A&M University and Emily Naiser, PhD, MPH, Project Director, Public Policy Research Institute, Texas A&M University

Involvement with the criminal justice system increases markedly during the transition from youth to adulthood in the United States. Providing targeted services and supports to vulnerable emerging adults during this transition may be an effective way of reducing the conditions and behaviors that lead to incarceration and its adverse health effects.  The research team led by Texas A&M University will use a randomized trial to test the effectiveness of the Transformative Justice (TJ) program in reducing criminal justice recidivism and improving health outcomes by coordinating health and social services for justice-involved young adults.  The program will assign a multi-sector case management team to individuals following their arrest for lower-degree felony offenses, connecting them to mental health, legal assistance, education, employment training, transportation, and housing services. The research team will collaborate with the Access to Justice Lab at Harvard Law School, the University of Texas Health Science Center, the Lone star Justice Alliance, and multiple local non-profits and county agencies to conduct the study.

Closing Gaps in Health and Social Services for Low-Income Pregnant Woman

Principal Investigators: Irene Vidyanti, PhD, Data Scientist, County of Los Angeles Department of Public Health and William Nicholas, PhD, Lecturer, Health Policy and Management, UCLA Fielding School of Public Health 

American cities face stubbornly large racial disparities in infant mortality, perterm and low birthweight births along with unacceptable rates of maternal mortality.  The Los Angeles Maternity Assessment Management Access and Service (MAMA) program is an innovative, multi-sector initiative that seeks to address the constellation of social factors that contribute to adverse maternal and infant outcomes, including housing instability, food insecurity, untreated mental health conditions, domestic violence, and substance abuse.  A research team led by Los Angeles County will test the effectiveness of the program’s four major components: (1) a health home care management model, (2) peer and community support, (3) flexible funding for non-medical services, and (4) an advanced health information technology platform.  The team will partner with the University of Southern California Children’s Data Network, Public Health Foundation Enterprises, and the county offices for child protection and probation to conduct the study.