This study, funded as part of the Robert Wood Johnson Foundation’s Systems for Action research program, 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.

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 Tomorrow (formerly 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.

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.

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 determinants 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.

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.

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.

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.

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 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.

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).

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.

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.

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.

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.

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.

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.

A vast majority of older Americans who are eligible for federal nutrition assistance programming remained un-enrolled, 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.

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 counseling, 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.