Inclusive Health Planning

Two people filling out a form on a clipboard. The person holding the clipboard is a doctor.

U.S. Potential Path to Addressing Health-Related Social Needs: Drawing Lessons from State Innovations

Today, 40% of Americans face significant material hardship, which includes limited access to vital resources such as nutritious food, medical care, affordable housing, and essential utilities. Yet, the support provided by social service agencies and nonprofit organizations reaches less than 16% of those struggling with material hardship, leaving the majority to manage on their own. What happens when someone cannot pay rent or has a disconnected phone? These unmet health-related


How can states build better relationships between Health Care Organizations and Community Based Organizations?

Healthcare providers, organizations, and payers recognize the connection between social needs and health outcomes. These social needs are often described as the social determinants of health (SDOH). SDOHs are the environmental and social factors that influence health outcomes. Research indicates that improving social conditions— such as adequate food, secure housing and income, access to healthcare, and dependable transportation — is crucial to addressing health inequalities and outcomes. With the increasing


#SystemsofCareInsights: Policymaker Insights. Rethinking Evaluations and Using Multiple Measures (3/3)

Rethinking Evaluations: Navigating services related to health– housing, employment, transportation, etc.– can be extremely difficult. That’s why state leaders in North Carolina created NCCARE360, a network that provides public access to resources and aids organizations in collaborating on referrals. As the first statewide coordinated care network, NCCARE360 has onboarded over 2,500 organizations and helped over 42,000 users. But how can state leaders even get started creating a network like NCCARE360?

systems of care insights 2

#SystemsofCareInsights: Accepting Tradeoffs and Capitalizing on Nuance (2/3)

Accepting Tradeoffs: Effective coordinated care networks require numerous moving parts to work together. Managers of these systems must acknowledge the inevitability of issues in their systems. When things go off course, it’s essential to recognize tradeoffs. Some metrics can be optimized at the expense of others. One of the main tradeoffs discovered by researchers in the IBM report is the interplay between accuracy versus efficiency. For coordinated care networks, better

systems of care insights 1

#SystemsofCareInsights: Beyond Network Effectiveness (1/3)

Systems of care allow clients to seamlessly receive care from multiple health and human service providers. They improve access to care and encourage accountability for health and human services organizations. Systems of care are defined as referral systems across health and human service agencies supported by technological capital (e.g., community referral technologies, updatable resource directories) and human capital (e.g., community health navigators, call center operators, social workers). The implementation of


Facts and Flux: An Updated Review of Active Referral Technologies

Referral technologies are a rapidly increasing and adapting addition to care operations in the United States. Not only are present technologies constantly updating and adapting their practices, but new platforms are implemented into the care continuum on an ongoing and rolling basis. In 2019, Yuri Cartier, Caroline Fichtenberg, and Laura Gottlieb produced a comprehensive review of the present nine primary community resource referral platforms in their publication, “Community Resource Referral