This study, funded as part of the Robert Wood Johnson Foundation’s Systems for Action research program, will assess the feasibility of implementing a community co-designed initiative that integrates health, social, public safety, and justice services under a single local government umbrella agency. The initiative focuses on improving the health, safety, and wellbeing of communities harmed by systemic racism and to reduce involvement in the criminal legal system.

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

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.

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.

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.

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.

American cities face stubbornly large racial disparities in infant mortality, preterm 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.