Collaborating Research Centers were funded from 2016 through 2020 as part of the S4A program to lead research initiatives that test innovative ways of integrating medical, public health, social, and community services. In addition to conducting systems alignment research, each center served as a...

This study evaluates the effectiveness of multi-sector Partnerships for Early Childhood Development (PECD) in maintaining social needs screening, referral, and service delivery for children during the COVID-19 pandemic in New York City. PECD is an initiative that provides funding and guidance to help pediatric primary care practices partner with community-based social service organizations to address the social needs of children and families.

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.

Elder abuse and neglect (EA/N) is a public health and safety epidemic with impacts in emergency department utilization, nursing home placement, mortality, and financial losses. Vulnerability has been shown to be highly correlated with EA/N victimization, yet research is lacking on interventions aimed at decreasing vulnerability. The principal investigators of this study are reviewing the impact of a primary prevention strategy for EA/N victimization: the community complex care response team (CCRT) intervention.

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).

Individuals under the U.S. probation system have higher incidences of health conditions including substance abuse and mental illness and are less likely to access health care and other social services, such as education, transportation, employment, and housing, than those not involved in the system. To investigate the process and impact of implementing a multi-agency “Culture of Health” team in the Delaware Department of Probation, the study combines the efforts of multiple agencies working across traditionally siloed systems, including the Departments of Health and Human Services, Labor, Housing, Education, and Correction.

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.

Involvement with the criminal justice system increases markedly during the transition from youth to adulthood in the United States. Providing targeted services and supports to vulnerable emerging adults during this transition may be an effective way of reducing the conditions and behaviors that lead to incarceration and its adverse health effects. The research team led by Texas A&M University uses a randomized trial to test the effectiveness of the Transformative Justice (TJ) program in reducing criminal justice recidivism and improving health outcomes by coordinating health and social services for justice-involved young adults.

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.

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.