Community in Action
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-based1. Multi-sector integration can be defined along a continuum, from smaller-scale service coordination to complete integration of multiple organizations and delivery systems2. Efforts can focus on improving collaboration across sectors, client pathways to service, or coordination and resource sharing across different levels of government3. 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 organizations4.
Expected Beneficial Outcomes (Rated)
Improved access to social services
Improved health outcomes
Other Potential Beneficial Outcomes
Increased enrollment in social services
Increased social service efficiency
Evidence of Effectiveness
There is some evidence that integrating social services can improve access to social services5, 6, 7, 8, 9 and improve health and health-related outcomes10, 11, 12, 13. Such efforts appear to increase access and enrollment, especially for veterans6 and vulnerable populations such as individuals experiencing homelessness and mental illness9, 14, 15. Social service integration is also a suggested strategy to reduce service gaps, fragmentation, and duplication1, 16, and better serve older adults with serious illnesses17 or multiple chronic conditions10. However, additional evidence is needed to confirm effects.
Available evidence suggests integration of clinic and community service systems may decrease health care costs10, 11, 12 and health disparities2, 11, and increase clinical and community capacity to provide on-site programs and services, service needs screening, and links to community resources18. Integrated programs may improve health-related outcomes for young children11, family outcomes among Native American families13, and increase access to social services and reduce use of health care services among high risk veterans experiencing homelessness19. Integrating health services in women’s shelter services may increase service access and satisfaction with services among women who have experienced intimate partner violence5. 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 children20.
Case studies and interviews suggest that successful efforts to integrate social and health services include a coordinating mechanism to manage collaboration and service delivery planning, quality measurement and data-sharing tools to track outcomes and share information, financing and payment methods that support and reward coordination21, 22, and cultural awareness and responsiveness among staff13. Stakeholder involvement, active interaction between service users, practitioners, and policy makers, strong commitment from an executive team, and aggressive marketing of mutual goals across agencies and departments can also improve service integration efforts16, 23, while separated budgeting by department appears to impede interagency service integration24. 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 members17.
Experts suggest that multi-sector social service integration combined with financial capability initiatives that increase access to banking, insurance, accounting, and credit services, financial education, or credit repair assistance may improve health, housing, education, and employment outcomes for eligible participants with low incomes25, 26. Case studies suggest multi-sector service integration including financial capability services may improve financial stability, increase savings and assets, and build wealth for participants with low incomes25, 26. Social service integration efforts that comprehensively address the needs of clients and communities may improve economic well-being, especially for people of color living in communities with concentrated poverty and suffering from systemic racism27.
Potential to decrease disparities: Supported by some evidence
There is some evidence that social service integration has the potential to decrease disparities in health outcomes and service access5, 10, 13. Available evidence shows that interagency partnerships can reduce health care spending and improve health outcomes among older adults10 and increase child wellbeing and safety for Native American families13. Integrating health and social services in women’s shelters may increase service access among women who have experienced intimate partner violence5. Intersectoral integration between social, health, and housing services is recommended to reduce service gaps, improve service access and health outcomes for individuals who have multiple social and medical unmet needs, such as older adults living in public housing34, individuals with serious mental illness17, 35, veterans6, individuals experiencing homelessness15, 19, children at risk of food insecurity36, first-time mothers and young children11, and communities affected by poverty and systemic racism27.
The federal government’s first efforts at social service integration were through the US Department of Health, Education, and Welfare’s (HEW) initiative to integrate child and family services in 1971. The HEW’s initiative included the Services Integration Targets of Opportunity (SITO) program that funded some state and local government pilot program reforms for interagency coordination37, 38. In 1984, the National Institute of Mental Health’s (NIMH) Child and Adolescent Service System Program (CASSP) provided grants to states and mental health agencies to support integrated services across mental health, education, public assistance, and juvenile justice areas for children with serious emotional disabilities37. Other service integration efforts during the 1980s included school-based comprehensive youth service programs; development of family support centers; and the introduction of case management and coordinated intake procedures for individuals involved in public assistance programs39.
- What social services would benefit the most from integration in your community? Who could help prioritize which services to integrate?
- How can service integration efforts reach vulnerable populations with multiple service needs such as victims of domestic violence or at-risk youth?
- How can service integration efforts build equitable and balanced partnerships between organizations and agencies with different capabilities, resources, and levels of cultural awareness?
- What resources are needed to provide continued services for communities with multiple social and health service needs?
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 government3. Some states have established integrated social service delivery systems through Medicaid Accountable Care Organizations (ACOs), as in Colorado, Maine, Minnesota, Oregon, and Vermont28. As of March 2022, the Centers for Medicare & Medicaid Services is testing the Accountable Health Communities (AHC) Model in 28 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 services29.
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 Nebraska30. 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 families31. Community centers can offer a “one-stop shopping” model of service that coordinates access to social services32. 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 areas18, 33.
‡ Resources with a focus on equity.
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.
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1 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.
2 Fichtenberg 2020 - Fichtenberg C, Delva J, Minyard K, Gottlieb LM. Health and human services integration: Generating sustained health and equity improvements. Health Affairs. 2020;39(4):567-573.
3 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.
4 Cheng 2019 - Cheng S, Catallo C. Case definition for health and social care services integrated initiatives. Journal of Integrated Care. 2019;27(4):264-275.
5 Mantler 2020 - Mantler T, Jackson KT, Walsh EJ. Integration of primary health-care services in women’s shelters: A scoping review. Trauma, Violence, and Abuse. 2020;21(3):610-623.
6 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):441-468.
7 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.
8 MDRC-WASC - Manpower Demonstration Research Corporation (MDRC). Work advancement and support center (WASC) demonstration.
9 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.
10 Brewster 2020 - Brewster AL, Wilson TL, Frehn J, Berish D, Kunkel SR. Linking health and social services through area agencies on aging is associated with lower health care use and spending. Health Affairs. 2020;39(4):587-594.
11 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.
12 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.
13 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.
14 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.
15 Mosley 2021 - Mosley JE. Cross-sector collaboration to improve homeless services: Addressing capacity, innovation, and equity challenges. Annals of the American Academy of Political and Social Science. 2021;693(1):246-263.
16 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.
17 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.
18 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.
19 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.
20 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.
21 CWF-McGinnis 2014 - McGinnis T, Crawford M, Somers SA. A state policy framework for integrating health and social services. Commonwealth Fund (CWF). 2014.
22 Mitchell 2020a - Mitchell C, Tazzyman A, Howard SJ, Hodgson D. More that unites us than divides us? A qualitative study of integration of community health and social care services. BMC Family Practice. 2020;21.
23 McCall 2021 - McCall V, Hoyle L, Gunasinghe S, O’Connor S. A new era of social policy integration? Looking at the case of health, social care and housing. Journal of Social Policy. 2021;50(4):809-827.
24 McCullough 2020 - McCullough JM, Leider JP, Phillips MA. Integration of health and social services at the systems level: A framework for addressing funding and jurisdictional silos. American Journal of Public Health. 2020;110(S2):S197-S203.
25 ACF-Bowen - Bowen R, Hattemer K, Griffin K. Building financial capability: A planning guide for integrated services. US Department of Health and Human Services, Administration for Children & Families (ACF), Prosperity Now. GSA Schedule Contract GS-10-F-0177L; Order No HHSP233201200674G.
26 CFED 2013 - Corporation for Enterprise Development (CFED). Integration & innovation: Lessons from organizations integrating asset building into social services. May 2013.
27 Irwin 2021 - Irwin MD, Amanuel Y, Bickers B, Nguyen MA, Russell OW. Impacts of the COVID-19 pandemic on preexisting racial and ethnic disparities, and results of an integrated safety net response in Arlington County, Virginia. Health Security. 2021;19(S1):S62-S71.
28 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.
29 CMS-AHC - Centers for Medicare & Medicaid Services (CMS). Accountable Health Communities Model (AHC).
30 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.
31 RHIhub-One-stop shop - Rural Health Information Hub (RHIhub). Rural services integration toolkit: One-stop shop model.
32 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).
33 UM-SNEI - Safety-Net Enhancement Initiative cross-site evaluation: Final report. The Center for Managing Chronic Disease, University of Michigan (UM); 2014.
34 Sheppard 2022 - Sheppard CL, Gould S, Guilcher SJT, et al. “We could be good partners if we work together:” The perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults. BMC Health Services Research. 2022;22:313.
35 Storm 2020 - Storm M, Fortuna KL, Gill EA, et al. Coordination of services for people with serious mental illness and general medical conditions: Perspectives from rural northeastern United States. Psychiatric Rehabilitation Journal. 2020;43(3):234-243.
36 Brochier 2022 - Brochier A, Garg A, Peltz A. Clinical and public policy interventions to address food insecurity among children. Current Opinion in Pediatrics. 2022;34(1):2-7.
37 Soler 1990 - Soler M, Shauffer C. Fighting fragmentation: Coordination of services for children and families. Nebraska Law Review. 1990;69(2):278-297.
38 Agranoff 1991 - Agranoff R. Human services integration: Past and present challenges in public administration. Public Administration Review. 1991;51(6):533-542.
39 Waldfogel 1997 - Waldfogel J. The new wave of service integration. Social Service Review. 1997;71(3):463-484.
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