Much of what makes people healthy happens outside the health care system. Social factors such as access to housing, healthy food, reliable transportation, and quality education can play a role in a host of health conditions, including asthma, diabetes, hypertension, and cardiovascular disease. Preventing and treating these conditions, and addressing the significant racial and ethnic health disparities that leave people of color with far worse health outcomes, cannot be achieved through clinical care alone.
Health care providers and community-based organizations that address social service needs represent different pieces of a puzzle: Each works on things that are critical to ensuring that people are truly healthy, but their work is not complete without the other. While they often serve the same people, health care providers and community-based organizations generally operate separately. If they worked together as partners, health care providers and community-based organizations could harness their combined expertise to improve the health and well-being of the people and communities they serve. Payers, such as Medicaid and commercial insurers, and philanthropy can also play critical roles in fostering these relationships. There is widespread agreement that developing and supporting clinical-community partnerships is critical to improving health outcomes, but it is not always clear how.
This report provides answers to the question of how to develop clinical-community partnerships and integrate care and services, with lessons from existing models and a step-by-step guide intended to offer guidance to those considering pursuing these partnerships.