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.

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.

Our program officer at the Robert Wood Johnson Foundation contributes to setting Systems for Action program priorities. She also reviews and recommends applications for funding.

Impact studies examine the impact of a novel system alignment strategy on relevant measures of health and wellbeing for affected populations. These studies build on pilot studies confirming the feasibility and acceptability of the systems alignment strategy and use rigorous research methods to...