Systems of Care and Social Impact

Table of Contents

The social environment we live in can significantly affect our health. Social determinants of health 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 key stages.

This resource guide answers common questions about the problems that Systems of Care solve and how to navigate them.

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 consist of three core elements:

The well-being of citizens will directly depend on the design, organization, and efficiency of these systems as a whole. Systems of Care generally address human service needs, behavioral health needs, and healthcare needs.

What technologies support Systems of Care?

There are three classes of technologies that support Systems of Care:

SoC 3 Technologies

What role do human navigators play in Systems of Care?

Human navigators can play multiple roles in Systems of Care. They can be…

  • call center operators, who support matching individuals with needs to the organizations that support those needs.
  • community resource advocates, who come alongside individuals or families, helping them reach their goals over time
  • community health workers or social workers, who 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. This allows them to predict next steps so the client can be sure to receive any help that they need and remain successful even after receiving assistance.

How can Systems of Care be evaluated?

Systems of Care can be evaluated using three indicators known 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.
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In our research about network effectiveness, we describe three data types that are useful for optimizing network management and improving performance. The use of these data types will help in evaluating the effectiveness of referral systems: 

Tracks the outcomes for clients and shows the performance of providers.

Tracked by county or state governments. Includes longitudinal data on public sector service utilization and interaction.

Necessary to calculate 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. 

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.  Be sure to check out our new white paper report focused on Systems of Care that address veteran-specific needs.

Without policymakers’ 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.