Better health outcomes are achieved through collaboration between health care and human services.

Health care organizations and community-based organizations that provide human services have started creative partnerships because collaboratively addressing the social determinants of health and medical care is the best way to improve the health of children, adults, and families. Together, they lower costs and improve health by addressing medical as well as social, environmental, and behavioral needs.

Much of health spending in the U.S. comes from treating a very small population. Five percent of the population accounts for 50 percent of health care spending in the U.S. Individuals in this population have complex clinical health and social needs due to the conditions in which they are born, grow, live, work, and age.

Health Conditions

  • Multiple chronic diseases
  • Mood and anxiety disorders
  • Substance use disorders
  • Severe mental illness

Social Conditions

  • Unstable housing and homelessness
  • High poverty
  • Community violence
  • Low education level
  • Non-English speaking
  • Racial or ethnic minority, immigrant or refugee status
  • Involved in public systems (e.g., criminal justice, juvenile justice, child welfare)
  • Uninsured, underinsured
  • Dual eligible beneficiaries
  • Social isolation, few social supports

Community-based organizations have the unique competencies that health care systems need.

Community-based organizations are equipped to effectively serve children, youth, and adults with complex health and social needs through these competencies: 

  • Multilevel screenings and assessments. Organizations’ protocols and tools align individual needs to a comprehensive array of social and health solutions
  • Navigating systems of care. Case management and care coordination services expertly navigate the myriad of systems, services, and providers that serve individuals with complex needs
  • Multi-setting service provision. Staff are adept in clinical, home, and community environments and can be embedded in schools, community centers, public housing authorities, and other settings
  • Evidence-based practice. Therapeutic programs, models, and services are evidence-based and uniquely designed to produce reliable outcomes
  • Professional, experienced staff. Social workers, psychologists, psychiatrists, nurses, and administrative/management staff have deep expertise in working with complex-needs individuals
  • Patient engagement and advocacy. Practices like motivational interviewing, coaching, and teaching of self-advocacy skills fully engage individuals in their own treatment
  • Culturally competent services. Cultural humility, culturally and linguistically appropriate practices, and peer supports reduce barriers to treatment and increase engagement
  • Community-anchored relationships. Established relationships with community members and neighborhood institutions allow organizations to build on years, even decades, of trust
  • Community advocates. Organizations champion, on behalf of individuals and families in their communities, policy, systems, and supports that sustain well-being

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