Systems of Care

Systems of Care that Make a Social Impact

The social environment we live in can significantly affect our health. Opportunities for maintaining a person’s health and well-being are closely related to the conditions in which his development and daily activities occur. The social determinants of health are the conditions in the environment in which people live, learn, work and age. They include five main concepts: economic stability, education, health and health care, neighborhood and environment, and social and community context.

Systems of care exist to maintain the health of citizens by influencing and improving the social determinants of health.

However, the agencies that address these social determinants of health have been siloed from medical organizations. Systems of care are navigation networks that allow individuals to move seamlessly across agencies and healthcare organizations to receive needed care. They support the help-seeking process – often providing support at several stages.

This resource guide answers common questions about what problems Systems of Care solve and how to navigate within them. We offer to understand why the quality of the environment is so vital to our well-being.

What are systems of care?

Systems of Care are organizational arrangements designed to support individuals in locating and obtaining valuable benefits, programs, and services. These systems of care consist of three core elements.

Systems of Care differ in that they include a broad understanding of the process of responding to the needs of people at risk. The well-being of citizens, in general, will directly depend on the design, organization, and efficiency of these systems as a whole. Systems of care generally address human service needs, behavior health needs, and healthcare needs.

What technologies support systems of care?

There are three classes of technologies that support systems of care:

  • Call center platforms, including community resource directory. They are created for those who do not have access to information about referral technologies. The quality of the service will depend on the operators’ skills and information in directories.
  • Case management technologies, including Customer Relationship Management (CRM) and information exchange systems . CRM is a technology that helps to control and manage communication with clients within their service. Information exchange services include multiple data systems to facilitate coordination between services due to the ability to share information at an individual level.
  • Community resource referral technology. This is an advanced shared referral technology that includes, in addition to the functions of information exchange technologies, feedback tracking of processes and results.

What role do human navigators play in systems of care?

Human navigators can play multiple roles in the systems of care. They can be call center operators that support matching individuals with needs to the organizations that support those needs. They can be community resource advocates, who come alongside individuals or families, helping them reach their goals over time. Community health workers or social workers can also become advocates as they work through a care coordination plan. 

Coordination centers can also play an important role. An interview with Hunter Russ, Associate Director of Service Coordination with Veteran Services of the Carolinas, reveals the complexity of the role. The coordinator’s task is not only to provide high-quality assistance to the client but also to thoroughly examine their situation to predict their next steps so the person can be sure to receive any help that he needs and is successful even after receiving assistance or first aid.

How can systems of care be evaluated?

Systems of Care can be evaluated using three indicators such as accuracy, efficiency, and effectiveness. 




how quickly a client receives services


whether the first referred organization provided services to the client


whether the client received services

In our research about network effectiveness, we show how the correlation of these three metrics assesses the systems of care. Also, three data types would be useful for optimizing network management and improving performance. The use of these data types will help in evaluating the effectiveness of referral systems: 

  • Closed-loop referral data that tracks the outcomes for clients and shows the performance of providers;
  • County and state government-tracked service utilization data that includes longitudinal data on public sector service utilization and interaction;
  • Cost of care datа that is needed to calculate the cost of care of clients across benefit programs. 

We briefly talked about each in our blog, and more fully describe why these data types are essential in the report “Mapping the navigation systems of Pennsylvania.”

What should policymakers do to support systems of care?

Federal policymakers in the United States have promoted Systems of Care interventions for over a decade. After the success of the federally funded  Areas on Aging, other federal agencies offered their own incentives to collaborate. HUD introduced Continuums of Care in 2010. CMS is promoting Medicare 1115 waivers to address the social determinants of health. As part of the new Hannon Act, the Fox grants program encourages a network approach to address veteran suicide. And the LINC act, under consideration, would create new network approaches to a broad range of human services

Policymakers should mandate the collection of four classes of metrics:



Quality control metrics

  • How many individuals seeking help should a human navigator interact with daily? Which navigators are exceeding or below that standard?
  • What training enables human navigators to make the best interventions in the client help-seeking process?
  • Which human navigators are making the best referrals? Which are best at helping individuals gather the necessary documentation for enrollment?

Demand metrics

  • From what zip codes do we receive the highest volume of requests for each service?
  • What are the demographics of individuals requesting services?
  • What kinds of services are most often requested?
  • What services are co-requested?

Supply metrics

  • How many requests does each provider receive?
  • What type of services are refused due to lack of capacity? Eligibility requirements?

Process metrics

  • How accurate are referrals?
  • How quickly do clients receive follow-ups from providers?
  • What percentage of clients fail to persist from referral to receiving services?
  • What is the time from referral received to services rendered?

Outcome and activity should be measured separately by type of service and by race, ethnicity, and gender. When agencies promote easiest services to provide, these generic measures can lead to misrepresentation of network outcomes. Also, by separation of outcome and activity metrics, it can be seen who receives the best and the worst assistance, allowing resource reallocation to meet the needs of underserved groups.

To properly evaluate networks, Congress should require tracking for three service categories (low, mid, & high complexity). In our research, high complexity services take far more time to complete and are often less successful at completing services. But, these service types are essential to the long term independent of individuals and families. Disaggregating metrics by service type can combat “cream-skimming” that might occur through incentivizing networks for focus on service types that are the fastest and easiest to provide. 

Municipal and county policymakers also have a role to play. Also, in different territories, the strategy of support will differ. For example in rural areas, due to the characteristics of settlement, policymakers can create new programs and services, which are not applicable to larger landscapes, due to the speed of change and implementation of a particular program. 

Project-based networks will be especially effective, where policymakers can invite employees to participate in various different task forces or working groups, which leads to reaching a wider audience. For example, in Grinnell, Iowa, the task forces have created several programs for school readiness, summer learning, and after-school enrichment which led to better than statewide increases in both 4th-grade and 8th-grade reading.

In urban areas, policymakers will play a decisive role in aligning social systems. Without their data systems and support, nonprofit and business networks don’t have the reach to move the needle on social issues for an entire community. Municipal and county leaders must first ensure that everyone collects data in the same way. Then they can propel networks to use this data to improve the quality of services and fill service gaps.