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, will assess the feasibility and acceptability of an intervention designed to align medical, public health, and social service systems to support integrated, culturally responsive early childhood care for Latino and farmworker families residing in California’s northern coast in order to prevent and manage early childhood developmental delays and disabilities. The intervention is designed to disrupt systemic racism in early childhood systems that limits access to care for minority communities—including language inaccessibility, fragmented referrals, disinvestment in clinical infrastructure, and institutional distrust—by redesigning access points around trusted community infrastructure.

This study, funded as part of the Robert Wood Johnson Foundation’s Systems for Action research program, pilot tests a novel community-embedded, technology-supported overdose response intervention that aligns medical care, public health, and social service systems to improve outcomes for persons following the experience of an overdose among people living in the Skid Row area of Los Angeles, CA. The intervention proposes to dismantle the structural racism that channels marginalized communities into overburdened low-resource medical systems with limited capacity to address underlying health and social needs, and that excludes these communities from having a voice in how these systems operate.

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, 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.

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.

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 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.

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.

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.

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.