Social service integration

Social service integration efforts coordinate access to services across multiple delivery systems and disciplinary boundaries such as housing, nutrition, disability, physical health, mental health, child welfare, transportation, and workforce services. Approaches to integrating and coordinating social services vary depending on community needs and service availability, and can be system- or sector-based, agency-based, or client- or family-based (King 2006*). Efforts can focus on improving collaboration across sectors, client pathways to service, or coordination and resource sharing across different levels of government (GI-Integration 2014*). Frequent features of collaborative social service integration include having common goals and a shared understanding of roles and responsibilities among organizational partners; sharing information about patients, care, and administration; and staff and professional interactions at all levels of organizations (Cheng 2019*).

Expected Beneficial Outcomes (Rated)

  • Improved access to social services

  • Increased social service efficiency

  • Improved health outcomes

Other Potential Beneficial Outcomes

  • Increased enrollment in social services

Evidence of Effectiveness

Integrating social services is a suggested strategy to improve access to social services (Fisher 2012*, Mathematica-Cody 2010, MDRC-Support center, Smith 2013*, Rosenheck 2001), reduce service gaps, fragmentation, and duplication (King 2006*, Packard 2013), and improve health and health-related outcomes (Tschudy 2013, IHI-Craig 2011*, Lucero 2012*). Such efforts appear to increase access and enrollment, especially for veterans (Fisher 2012*) and vulnerable populations such as individuals experiencing homelessness and mental illness (Guerrero 2014*, Rosenheck 2001). Social service integration is also recommended to better serve older adults with serious illnesses and individuals with disabilities (Golden 2019a*, Smith 2013*). However, additional evidence is needed to confirm effects.

Available evidence suggests integration of clinic and community service systems may decrease health care costs (Tschudy 2013, IHI-Craig 2011*) and health disparities (Tschudy 2013), and increase clinical and community capacity to provide onsite programs and services, service needs screening, and links to community resources (Lachance 2016*). Integrated programs may improve health-related outcomes for young children (Tschudy 2013), family outcomes among Native American families (Lucero 2012*), and increase access to social services and reduce use of health care services among high risk homeless veterans (O’Toole 2016). Studies in Australia, Canada, and New Zealand have shown intersectoral social service integration can improve service utilization, satisfaction, and health outcomes for children with mental health issues, especially among tribal and indigenous children (Lopez-Carmen 2019*).   

Case studies and interviews suggest that successful efforts to integrate social services include a coordinating mechanism to manage collaboration, quality measurement and data-sharing tools to track outcomes and share information, financing and payment methods that support and reward coordination (CWF-McGinnis 2014), and cultural awareness and responsiveness among staff (Lucero 2012*). Stakeholder involvement, strong commitment from an executive team, and aggressive marketing of mutual goals across agencies and departments can also improve service integration efforts (Packard 2013). Incentives for team-based care across the continuum of services, adequate salaries, and academic loan forgiveness are recommended to recruit and retain high quality team members (Golden 2019a*).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

States are working to coordinate and integrate social services. Many states have restructured service delivery to improve public, non-profit, and private sector collaborations, develop place-based service integration, enhance client pathways to service, and coordinate programs and resource sharing across different levels of government (GI-Integration 2014*). Some states have established integrated social service delivery systems through Medicaid Accountable Care Organizations (ACOs), as in Colorado, Maine, Minnesota, Oregon, and Vermont (CHCS-Mahadevan 2015). As of February 2020, the Centers for Medicare & Medicaid Services is testing the Accountable Health Communities (AHC) Model in 30 participating organizations across the country; the AHC model initiative identifies and addresses health-related social needs among Medicare and Medicaid beneficiaries by connecting clinical care and community services (CMS-AHC).  

Several counties and states have adopted one-stop office models of service. Examples include San Mateo County, CA; Mesa and El Paso County, CO; Bibb County, GA; Jefferson County, KY; Montgomery County, OH; Coos and Jackson Counties, OR; Fairfax County, VA; Racine and Kenosha Counties, WI; and the state of Nebraska (Rockefeller Institute-Service integration). Florissa is an example of a rural one-stop shop model in northwest Illinois: a centralized facility houses multiple disciplines from each partnering organization and addresses developmental, behavioral, social, and emotional needs of rural children and their families (RHIhub-One-stop shop). Community centers can offer a “one-stop shopping” model of service that coordinates access to social services (CDC-Community center). The Kresge Foundation funds the Safety-Net Enhancement Initiative that includes efforts to integrate clinical and community systems in underserved communities in both urban and rural areas (UM-SNEI, Lachance 2016*).

Implementation Resources

RHIhub-One-stop shop - Rural Health Information Hub (RHIhub). Rural services integration toolkit: One-stop shop model.

CWF-McGinnis 2014 - McGinnis T, Crawford M, Somers SA. A state policy framework for integrating health and social services. Commonwealth Fund (CWF). 2014.

Citations - Evidence

* Journal subscription may be required for access.

Fisher 2012* - Fisher MP, Elnitsky C. Health and social services integration: A review of concepts and models. Social Work in Public Health. 2012;27(5):441–68.

Mathematica-Cody 2010 - Cody S, Reed D, Basson D, et al. Simplification of health and social services enrollment and eligibility: Lessons for California from interviews in four states. Princeton: Mathematica Policy Research (MPR); 2010.

MDRC-Support center - Manpower Demonstration Research Corporation (MDRC). Work advancement and support center demonstration.

Smith 2013* - Smith TJ. One Stop Service Center Initiative: Strategies for serving persons with disabilities. Journal of Rehabilitation. 2013;79(1):30-36.

Rosenheck 2001 - Rosenheck R, Morrissey J, Lam J, et al. Service delivery and community: Social capital, service systems integration, and outcomes among homeless persons with severe mental illness. Health Services Research. 2001;36(4):691–710.

King 2006* - King G, Meyer K. Service integration and co-ordination: A framework of approaches for the delivery of co-ordinated care to children with disabilities and their families. Child: Care, Health, and Development. 2006;32(4):477-492.

Packard 2013 - Packard T, Patti R, Daly D, Tucker-Tatlow J. Implementing services integration and interagency collaboration: Experiences in seven counties. 2013;37(4):356-371.

Tschudy 2013 - Tschudy MM, Toomey SL, Cheng TL. Merging systems: Integrating home visitation and the family-centered medical home. Pediatrics. 2013;132(SUPPL.2):74-81.

IHI-Craig 2011* - Craig C, Eby D, Whittington J. Care Coordination model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011.

Lucero 2012* - Lucero NM, Bussey M. A collaborative and trauma-informed practice model for urban Indian child welfare. Child Welfare. 2012;91(3):89-112.

Guerrero 2014* - Guerrero EG, Henwood B, Wenzel SL. Service integration to reduce homelessness in Los Angeles County: Multiple stakeholder perspectives. Human Service Organizations: Management, Leadership & Governance. 2014;38(1):44-54.

Golden 2019a* - Golden RL, Emery-Tiburcio EE, Post S, Ewald B, Newman M. Connecting social, clinical, and home care services for persons with serious illness in the community. Journal of the American Geriatrics Society. 2019;67(S2):S412-S418.

Lachance 2016* - Lachance LL, Friedman Milanovich AR, Garrity AN. Clinic and community: The road to integration. American Journal of Preventive Medicine. 2016;51(6):1072-1078.

O’Toole 2016 - O’Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring care to vulnerable populations by incorporating social determinants of health: The veterans health administration’s “Homeless Patient Aligned Care Team” program. Preventing Chronic Disease. 2016;13(3):1-12.

Lopez-Carmen 2019* - Lopez-Carmen V, McCalman J, Benveniste T, et al. Working together to improve the mental health of indigenous children: A systematic review. Children and Youth Services Review. 2019;104.

CWF-McGinnis 2014 - McGinnis T, Crawford M, Somers SA. A state policy framework for integrating health and social services. Commonwealth Fund (CWF). 2014.

Citations - Implementation Examples

* Journal subscription may be required for access.

GI-Integration 2014* - Governing Institute (GI), KPMG Government Institute. The integration imperative as the driver of reform: US state and local government innovations in human and social services delivery. 2014.

CHCS-Mahadevan 2015 - Mahadevan R, Houston R. Supporting social service delivery through Medicaid Accountable Care Organizations: Early state efforts. Center for Health Care Strategies (CHCS). 2015.

CMS-AHC - Centers for Medicare & Medicaid Services (CMS). Accountable Health Communities Model (AHC).

Rockefeller Institute-Service integration - Nelson A. Rockefeller Institute of Government. Building better human service systems: Integrating services for income support and related programs: June 2003.

RHIhub-One-stop shop - Rural Health Information Hub (RHIhub). Rural services integration toolkit: One-stop shop model.

CDC-Community center - Alcaraz R. New community center to prevent youth violence. Atlanta: Centers for Disease Control and Prevention (CDC), US Department of Health and Human Services (US DHHS).

UM-SNEI - Safety-Net Enhancement Initiative cross-site evaluation: Final report. The Center for Managing Chronic Disease, University of Michigan (UM); 2014.

Lachance 2016* - Lachance LL, Friedman Milanovich AR, Garrity AN. Clinic and community: The road to integration. American Journal of Preventive Medicine. 2016;51(6):1072-1078.

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