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 Colorado Anschutz Medical Campus, 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.


Can California's CalAIM Medicaid Transformation Initiative Achieve Systems Integration? Identifying Key Facilitators of Cross-Sectoral Coordination for Individuals with Complex Needs or at High Risk

Principal Investigators: Caroline Fichtenberg, PhD, Co-Director of Social Interventions Research and Evaluation Network (SIREN), Center for Health & Community, University of California San Francisco and Laura Gottlieb, MD, MPH, Co-Director of SIREN, Center for Health & Community, University of California San Francisco

This study evaluates the effectiveness of California’s CalAIM Medicaid Waiver program in integrating social service and public health organizations into Medicaid coordinated systems of care for individuals with complex health and social needs.  CalAIM is designed to dismantle forms of structural racism by investing nearly $2 Billion in helping Medicaid health plans and medical providers forge stronger alliances with local social service organizations and public health agencies in addressing the complex health and social needs of Medicaid beneficiaries, including paying for nonmedical services needed by these beneficiaries.  The study uses a sequential mixed-method research design to assess how well CalAIM succeeds in integrating social service and public health organizations into Medicaid systems of care, with a specific focus on Black, Indigenous, LatinX, and other persons of color. Activities include surveys of community organizations in 20 counties combined with in-depth case studies in five counties.  The study is conducted by the University of California at San Francisco in collaboration with 211 San Diego, United Way local affiliates, Health Leads, and other community partners.

An Aligned Delivery and Financing Model to Address Food Insecurity and Social Needs of Low-Income Pregnant Women

Principal Investigators: Elaine Borawski, PhD, Angela Bowen Williamson Professor of Community Nutrition at Case Western Reserve University and Alissa Glenn, MSPPM, Director of Community Health and Nutrition at the Greater Cleveland Food Bank

This study evaluates the effectiveness of an aligned service delivery and financing model designed to improve maternal and infant health by helping Medicaid-eligible persons receive access to healthy foods during pregnancy.  The Nourishing Beginnings program uses integrated data, screening and referral systems combined with community health worker support to link people in need with healthy food delivery from a local food bank or with direct cash assistance for food purchases.  The study uses a randomized controlled trial to evaluate the comparative effectiveness of the program, including the relative advantages of providing food delivery versus cash assistance.  The study is conducted by Case Western Reserve University in collaboration with the Greater Cleveland Food Bank, the Cleveland Department of Public Health, United Way of Cleveland, CareSource, MetroHealth, University Hospitals, and other community partners. 

Systems Alignment to Optimize Health Services for Youth Experiencing Homelessness

Principal Investigator: Janna Gewirtz O'Brien, MD, MPH, Assistant Professor of Pediatrics at the University of Minnesota

This study tests the feasibility of an integrated system of medical, social and public health programming designed to improve outcomes for youth experiencing homelessness in Hennepin County, Minnesota.  The study organizes community-engaged consensus building sessions with stakeholders from medical, social and public health systems and with youth experiencing homelessness in order to co-create strategies for system alignment, including multi-sector data integration, shared clinical practice guidelines, and co-location of health and social services for youth experiencing homelessness. Focus groups and interviews with key stakeholders are used to assess the feasibility of implementing the proposed system alignment strategies.  The study is conducted by the University of Minnesota's Youth Health and Housing Lab in collaboration with the Hennepin County Youth Homelessness Demonstration Program, the Minnesota Department of Health, the Hennepin Healthcare system, Minnesota Community Care, and local youth serving agencies.

Tribal Care Coordination Dashboard Project: Coeur Adolescent Support Team (CAST) Referrals

Principal Investigator: Elva "Cookie" Allan, MPA, MURP, Director, Strategic Initiatives & Development, Coeur d'Alene Tribe

This study tests the feasibility of a multi-sector tribally-operated data system and dashboard for documenting health and social service needs and service referrals among youth members of the Coeur d’Alene tribe. The integrated data system is designed to achieve data sovereignty and improve timeliness and coordination in the delivery of health and social services for the tribal youth population, thereby dismantling forms of structural racism and inequity created by reliance on fragmented non-tribal service delivery and financing systems.  The study employs user-centered design principles to develop and test a dashboard system that facilitates recruitment of youth from community service providers, assessment of youth for health and social needs, coordination of service referrals and utilization, and measurement of outcomes.  The feasibility and acceptability of the dashboard system are assessed by tracking measures of service referrals and timeliness of referrals, along with qualitative interviews with tribal service providers concerning ease of use and utility.  Results from the study will be used to plan a larger randomized study to evaluate the impact of the data dashboard on relevant health and social outcomes.  The study is conducted by the Coeur d’Alene Tribe including the Indian Child Welfare Program, the Marimn Health tribal medical system, the tribal Department of Education, and other tribal agencies in collaboration with the University of Idaho Extension Program.   

FAAITH (Faith-leaders Allied and Aligned to Institute Trust in the Home) and HOPE (Healthy Outcomes from Positive Experiences) for Equitable Systems Alignment

Principal Investigators: Allison Stephens, PhD, Director of Networks and Policy at the Center for Community-Engaged Medicine, Healthy Outcomes from Positive Experiences (HOPE) at Tufts Medical Center and Rev. Darrell Armstrong, MDiv, EdS, Pastor, Shiloh Baptist Church of Trenton and President and CEO at Shiloh Community Development Corporation

This study evaluates the feasibility of a modified church-based home visiting program that aims to align medical, public health, and social service systems for families with children while also dismantling forms of structural racism that can create barriers to access. The program is delivered by Shiloh Baptist Church in Trenton New Jersey, a predominantly Black congregation, and will integrate the research-based HOPE (Healthy Outcomes from Positive Experiences) framework into the program. The study includes a racial equity needs assessment conducted with church leaders and congregants, the development and testing of training content designed to help families and faith leaders implement child development practices, and a quality improvement process conducted that introduces new racial equity and child development practices into the existing program. The study also develops evaluation measures for use in a subsequent randomized trial to evaluate the impact of the revised home visiting program. The study is conducted by Tufts Medical Center in collaboration with FAAITH and Shiloh Baptist Church, Capitol County Children’s Collaborative, the Children’s Home Society of New Jersey, Prevent Child Abuse New Jersey, Henry J. Austin Health Center, Central Jersey Family Health Consortium, the City of Trenton, the Capital Health System, and Robert Wood Johnson University Hospital Hamilton.

Achieving Reach in Youth Behavioral Health and Wellness through Catchment-Area Community Governance

Principal Investigator: Sarah Walker, PhD, Research Associate Professor of the Department of Psychiatry and Behavioral Sciences at The University of Washington

This study evaluates the feasibility of the Youth Wellness Hub as a hyper-local community governance model for integrating delivery and financing systems for youth behavioral health and wellness services.  The Youth Wellness Hub combines three social policy tools that are separately promising or well-supported in the research literature: community governance; public health education campaigns; and service network coordination through fiscal blending.  The study uses a mixed-methods approach to assess feasibility of the model as tested in Tacoma, Washington, including surveys and interviews with community organizations together with a network analysis of these organizations.  The study is conducted by the University of Washington in collaboration with the Excelsior Center for Health and Wellness, the Safe Streets Coalition, and other community partners.

Research to Understand Systems of Housing (RUSH): Feasibility and Acceptability of Aligning Systems for Fathers

Principal Investigators: Latrice Rollins, PhD, Assistant Professor, Morehouse School of Medicine and Thomas Cotton, III, CEO, Redemption & Advancement Alliance, Inc.

This study evaluates the feasibility of a multi-sector “Functional Zero” approach to reducing homelessness among fathers in Atlanta, with a focus on Black fathers who are disproportionately represented among homeless populations.  The study builds from an existing multi-sector coalition of leaders from medical, social and public health sectors who have formed Fathers Matter ATL in which one of its strategies is working to address the unmet health and social needs of homeless fathers, including forms of structural racism that limit the availability of housing options for homeless men with dependent children.  The study uses qualitative interviews with service providers together with data from a service referral tracking database and the results of system mapping analyses to identify barriers and opportunities for achieving “Functional Zero” in the incidence of homelessness among the target population of fathers experiencing housing insecurity.  The study is conducted by the Morehouse School of Medicine in collaboration with Redemption and Advancement Alliance, Morehouse Healthcare, Good Samaritan Health Center, Fulton County Board of Health, and the Atlanta Housing Authority.


Integrating Health and Social Services through a Novel Independent Practice Association

Principal Investigators: Jonathan G. Shaw, MD, MS, Clinical Associate Professor, Associate Chair, Community Partnership Medical Co-Director, Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine and Todd Wagner, PhD, Professor (Research) at the Department of Surgery, Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research, Director at the Health Economics Resource Center, Stanford University School of Medicine

This study investigates the impact of a novel independent practice association (IPA) formed among community-based social service organizations (CBOs) to address social determinants of health among residents of upstate New York. The Healthy Alliance IPA allows diverse CBOs offering services for housing, transportation, food, and other social needs to join together in a shared-governance association that facilitates referrals, care coordination, and performance-based contracting with health plans and medical providers. A quasi-experimental research design is used to compare patients residing in counties served by the Healthy Alliance IPA with a matched comparison group of patients from other counties, using measures of healthcare utilization, social service utilization, and total cost of care. The study focuses specifically on the outcomes experienced by racial and ethnic minority populations and also examines the roles played by CBOs led by Black, Indigenous, Latino and other persons of color.  The research team is led by Stanford University School of Medicine in partnership with the Healthy Alliance IPA, Albany County Department of Health, Rensselaer County Department of Health, and other community partners.

Multisector Task-Sharing to Improve Mental Health in Harlem, NY

Principal Investigator: Victoria Ngo, PhD, Associate Professor, Department of Community Health and Social Sciences, Director, Center for Innovation in Mental Health, Director of Global Mental Health, Center for Immigrant, Refugee, and Global Health Adjunct Behavioral Scientist, RAND Corporation

This study evaluates the effectiveness of a multisector task-sharing collaborative in addressing the inter-related problems of mental health disorders, poverty, and housing instability among racial and ethnic minority communities residing in Harlem, New York. The collaborative trains the staff at low-income housing agencies and primary care practices to engage in mental health task-sharing, whereby staff deliver basic mental health support services such as screening, psychoeducation, peer support, and referral to mental health specialists. Community health workers are placed at these same sites to help connect clients with needed social services beyond housing and primary care. A randomized controlled trial is used to evaluate the impact of the task-sharing model on mental health, social functioning, employment, and quality of life. The study is conducted by the Harlem Strong Mental Health Coalition, led by the City University of New York (CUNY) in partnership with the Harlem Congregation for Community Improvement, Healthfirst Managed Care, and Coordinated Behavioral Care.

Social Bonds as a Pooled Financing Mechanism to Address Social Drivers of Health Equity

Principal Investigators: Pinar Karaca-Mandic, PhD, Professor, Carlson School of Management and Rahul Koranne, MD, MBA, Professor, Carlson School of Management

This study investigates whether a novel type of social bond can pool resources across multiple competing health plans and create stable, long-term financing for interventions that address Social Influencers of Health. The bond's design would allow multiple health plans participating in Minnesota’s Medicaid program to invest collectively in a fund that finances community-based interventions targeting social issues such as food insecurity, housing instability, transportation, and structural racism. Specific bond features allow the financial risks and returns from these interventions to be distributed equitably across health plans and other potential investors, while targeting funding to interventions that promote racial equity and health equity. The study uses community participatory approaches to engage local health and social service stakeholders in the design of the bond instrument. Monte Carlo simulation methods are used to estimate the impact of bond financing on health and social outcomes for racial and ethnic minority populations over time, while also estimating economic returns to health plans, Medicaid and other investors. The research team is led by the University of Minnesota in partnership with the Minnesota Hospital Association, Minnesota Association of Health Plans, Minnesota Department of Human Services, Minnesota Department of Health, and other community partners.

Changes in Capacity to Absorb Clinical-to-Community Referrals during the COVID-19 Pandemic

Principal Investigators: Charlene Altenhain, Executive Director, The Glasser/Schoenbaum Human Services Center and Danielle Varda, PhD, CEO of Visible Networks Lab

This study assesses the capacity of community social services organizations and their partners to meet the needs of new clients identified through emerging social determinants of health (SDOH) screening and referral tools used by medical providers during the COVID-19 pandemic. In a previous study, researchers developed a method for assessing the capacity of social service organizations to accommodate referrals from medical providers. In this follow-up study, a team based at Glasser/Schoenbaum Human Services Center and Visible Networks Lab use social network analysis, secondary data, and qualitative interviews to  explore how clinical-community referral networks and referral patterns have changed during the COVID-19 pandemic, and how these changes may affect service delivery and outcomes for community residents. Findings will guide efforts to strengthen the capacity of communities to meet the health and social needs of their residents.  

Using Whole Person Care to Coordinate Health and Social Services for Medicaid Populations during the COVID-19 Pandemic

Principal Investigators: Nadereh Pourat, PhD, Professor at University of California, Los Angeles
Emmeline Chuang, PhD, Associate Professor at University of California, Berkeley

This study evaluates the effectiveness of California’s Whole Person Care (WPC) initiative in coordinating health and social services for Medicaid beneficiaries with complex needs during the COVID-19 pandemic. Projects underway in 26 counties engage Medicaid health plans, medical providers, mental health agencies, social service organizations, and public health agencies in collaborative models of care and payment that target specific population groups with complex needs in each county, including people experiencing homelessness, those transitioning from incarceration, and patients with multiple chronic medical conditions. Using a quasi-experimental research design, researchers assess changes in collaborative community networks, service delivery patterns, and patient outcomes for program participants and matched comparison groups across 26 county-level projects before and after the onset of the COVID-19 pandemic.  The study analyzes data from network surveys, Medicaid claims data, and key-informant interviews to assess program effectiveness from multiple perspectives.  Researchers from the University of California-Los Angeles and University of California-Berkeley are collaborating with the California Department of Health Care Services to conduct the study.  

Effectiveness of Homeless Service Networks in Coordinating Services During COVID-19 

Principal Investigators: Hee Soun Jang, PhD, Associate Professor at University of North Texas and Jesús N. Valero, PhD, Assistant Professor at University of Utah

This study assesses the effectiveness of Continuum of Care homeless service networks (CoCs) in addressing health and social service needs created by the COVID-19 pandemic  for populations  experiencing homelessness. CoCs use cross-sectoral collaborations to integrate delivery of medical care, public health and social services for people experiencing homelessness. This study uses case studies, national survey data of CoC networks, and secondary data analysis to compare previous performance to new evidence of the successes and challenges CoC homeless service networks experience during the pandemic. Researchers from the University of North Texas and the University of Utah will collaborate to complete the study. Findings will be used to understand the effects of the pandemic on CoC homeless service networks and the effectiveness of the networks in achieving health equity during COVID-19. 

Multi-Dimensional COVID-19 Control in US: Identifying Counties with High and Low Levels of Success

Principal Investigators: Alison Gemmill, PhD, Assistant Professor at Johns Hopkins Bloomberg School of Public Health and Beth Resnick, DrPH, MPH, Senior Scientist and Director, Office of Public Health Practice and Training at Johns Hopkins Bloomberg School of Public Health

This study examines how the allocation of resources across medical, social, and public health services at the county level influences the relative success in controlling the progression of the COVID-19 pandemic.  The project focuses on resource allocation decisions across sectors as a collective impact process that may influence the ability of organizations to cooperate effectively across sectors in responding to the pandemic. Researchers from Johns Hopkins University will collaborate with the National Association of County & City Health Officials (NACCHO), representatives of public health, medical care, and social services sectors to complete the study. Findings will be used to inform counties on how spending allocations for medical, social and public health services can improve population health during a pandemic.

Effectiveness of Early Childhood Development Partnerships in Addressing Pediatric Health and Social Needs during the COVID-19 Pandemic

Principal Investigator: Margaret Paul, PhD, Assistant Professor at New York University Grossman School of Medicine

This study evaluates the effectiveness of  multi-sector Partnerships for Early Childhood Development (PECD) in maintaining social needs screening, referral, and service delivery for children during the COVID-19 pandemic in New York City. PECD is an initiative that provides funding and guidance to help pediatric primary care practices partner with community-based social service organizations to address the social needs of children and families. Findings will identify how preexisting and emergent partnerships have changed in response to the pandemic, and how these changes have influenced the resiliency and sustainability of services needed by children and families. Researchers at New York University are collaborating with clinical and community partners in the PECD collaborative to complete the study. 

Transit and Treatment: Effectiveness of Transit System to Improve Substance Abuse and Mental Health in Connecticut

Principal Investigators: Jeffrey P. Cohen, PhD, MA, Professor at the University of Connecticut and Carla J. Rash, PhD, Associate Professor at Department of Medicine at UCONN Health

This study tests how a transit system can enhance substance abuse treatment outcomes and reduce provider-level treatment costs for substance abuse amidst the opioid crisis in Connecticut. Increasing access and retention in treatment services is critical to improving health outcomes and reducing substance abuse overdose deaths. Using a difference-in-differences method, the research project will test how treatment costs differ before and after a new transit line and/or a change in transit service schedules. With empirical evidence on how transit schedules and lines impact costs and health outcomes, researchers will leverage relationships with state, transit officials, and public health agencies to implement a systems alignment plan that sustains transit lines and schedules that pass closer to treatment providers offer transit spurs to treatment providers, and/or encourage treatment providers to relocate closer to existing transit routes. Researchers at the University of Connecticut will collaborate with an ongoing advisory panel made up of CT treatment providers, the CT Department of Transportation, CT Department of Public Helath, and the Department of Mental Health and Substance Abuse. Findings will be moved in to action through the ongoing advisory panel to disseminate findings locally, regionally, and nationally.

Aligning Health and Social Systems to Expand Evidence-Based Home-Visiting

Principal Investigators: Venice Ng Williams, PhD, MPH, Assistant Professor, CU Anschutz Medical Campus, Prevention Research Center for Family & Child Health, Gregory J. Tung, PhD, MPH, Associate Professor, Colorado School of Public Health, and Mandy A. Allison, MD, Children's Hospital Colorado

This study tests the effectiveness of multi-sector financing and delivery strategies in expanding the reach and impact of the Nurse-Family Partnership (NFP) program across the U.S. Despite rigorous evidence of its ability to improve health and social outcomes for low-income pregnant women and their children, the NFP home visiting program currently reaches only a small proportion of the communities and families who could benefit from it. The study will use national, longitudinal data on NFP sites across the U.S. to estimate how alternative forms of multi-sector community collaboration influence program implementation and outcomes, including comparisons between healthcare-financed sites and social service-financed sites.  Researchers at the University of Colorado are collaborating with the NFP National Service Organization, Illuminate Colorado, and Children's Hospital Colorado to conduct the study.  Findings will be used in case studies of high-performing NFP sites and best practice models that community stakeholders can use to enhance NFP implementation and financing.

Aligning Delivery and Finance Systems to Prevent Adverse Child Experiences in St. Louis

Principal Investigators: Melissa Jonson-Reid, PhD, MSW, Director of PhD Program in Social Work, Ralph & Muriel Pumphrey Professor of Social Work Research and Patricia Kohl, PhD, Associate Professor at the Brown School at Washington University

This study tests an innovative model for preventing child maltreatment and adverse child experiences (ACEs) by aligning health and social services for vulnerable families in St. Louis.  The Parents and Children Together - St. Louis (PACT-STL) initiative braids together services and funding streams from multiple sectors to assist families with children who are referred to child protective services (CPS) for first-time and low-severity problems. This study uses a mixed-methods design to evaluate the initiative's effects on cross-sector relationships among community organizations, access to needed services among parents and children, and subsequent CPS referrals and costs. Researchers at Washington University's Brown School of Social Work are collaborating with Vision for Children at Risk, Missouri Department of Social Services, St. Louis Housing Authority, St. Louis Department of Health and other community organizations across the city to conduct the study. Findings will be used to assist other communities in implementing successful financing and service delivery models for preventing ACEs.

Using Global Budgets and Multi-Sector Teams to Align Systems in Vermont

Principal Investigator: Adam J. Atherly, PhD, Seymour and Ruth Perlin Professor of Health Administration and Internal Medicine at Virginia Commonwealth University

This study tests the effectiveness of a global all-payer payment model combined with multi-sector community health teams in improving health and social outcomes for Vermont residents.  The Vermont Blueprint for Health initiative is among the most ambitious statewide health financing reforms now underway in the U.S. The study uses quasi-experimental methods to estimate the reform's effects on relationships among health and social service organizations, access to needed health and social services, healthcare utilization and costs, and equity in health outcomes. Researchers at the University of Vermont are collaborating with the Department of Vermont Health Access, OneCare Vermont, and the Green Mountain Care Board to conduct the study. Results will provide state and federal decision-makers with strategies for using global budgeting and multi-sector teams to achieve systems alignment.












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 and 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 and 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.






Weaving the Tasina Luta: A Community-Based Participatory Research Approach to Implementation and Engagment with a Tribal Public Health Plan

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 California, 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: Jesús N. 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, Director of Research Translation and Capacity Building for the UPMC Center for High-Value Health Care and Lisa Dillman, PhD, Benefits Data Trust Senior Research Manager

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 and the UPMC Center for High-Value Healthcare will study the health and economic effects of a novel health plan strategy to increase benefit program enrollment. Using enrollment data from the Pennsylvania Department of Human Services, the UPMC Health Plan and Benefits Data Trust will determine which of their low-income dual eligible (enrolled in Medicare and Medicaid) members are eligible but not enrolled in the federal Supplemental Nutrition Assistance Program (SNAP), and proactively assist these members with enrollment. By matching this enrollment data with UPMC claims data, the team will use a randomized controlled trial to determine the impact of SNAP enrollment on 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 examine strategies that use regional, multi-sector governing boards to help organizations work together in coordinating services for children and families 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 Kajetan Wyczalkowski, PhD, Post-Doctoral Researcher, Georgia State University 

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 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, Los Angeles County Chief Information Office and William Nicholas, PhD, Director, Center for Health Impact Evaluation, Los Angeles County Department 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.