Overview

Population and individual health are significantly influenced by nonclinical factors. These social determinants of health range from individuals' knowledge and behaviors to community-level characteristics, resources, and conditions. Problematically, the expertise and infrastructure for addressing these multiple and diverse challenges to health are divided among the medical care, public health, and social and community services systems. Moreover, these systems often fail to work collaboratively. Integrated service delivery—seamless provision of a mix of complementary social, behavioral, and medical services by multiple providers—has potential to improve health outcomes by overcoming the misalignments between medical and community systems. The objective of this project is to determine the impact of social, behavioral, and medical integrated services on the health of an urban safety-net population. We report the preliminary findings from our research center's retrospective analysis of an integrated service delivery program at multiple federally qualified health center (FQHC) sites. The FQHCs offer integrated service delivery under the label of wrap-around services. Teams of licensed social workers, care managers, peer recovery coaches, behavioral health specialists, and primary care providers collaborate on patient care. The team provides pharmacy services, financial counseling, social work, dietician services, dental and integrated mental health and health coordination in the primary care setting. The effectiveness of integrated service delivery was modeled in 12 years of a population's longitudinal clinical and utilization data. The outcomes of interest were overall utilization, attributable costs, and condition specific prevention and quality indicators.

Details

Project: Improving Population and Clinical Health with Integrated Services and Decision Support
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