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.

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.

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.

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.

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

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.