The U.S. health care system is increasingly embracing the importance of identifying and acting on social determinants of health (SDOH), given their known impact on morbidity and mortality. Certain vulnerable populations, in particular, often have overlooked social needs, such as access to housing, transportation, healthy foods and employment support. In response, more and more health care organizations are pursuing partnerships with community-based organizations (CBOs) — e.g., housing organizations, workforce development agencies, food banks, and early childhood education providers — to meet both the medical and social needs of the populations they serve. Locally based CBOs are well positioned to identify and address unmet social needs since they are so closely connected to the populations they serve and familiar with the environments in which they live and work.

Development of these relatively new, cross-sector relationships is happening under a variety of partnership models. Through care coordination and the integration of social needs assessments and referrals into care delivery, CBO-health care organization partnerships aim to: (1) influence patient and provider behaviors that result in improved care quality and healthier lives; (2) facilitate clinical-community linkages to address a broad range of SDOH; (3) design systems to meet patient-identified needs; and (4) align with key operational and financial features of alternative payment models.

Potential benefits of these emerging partnerships include:

• Improved health outcomes;
• Lower costs for health systems from averting preventable re-hospitalizations and emergency department visits;
• Additional revenue streams for CBOs and the opportunity to reach more community members; and
• More efficient allocation of social safety net resources to better meet consumers’ needs.

Uncovering the Elements of Successful Partnerships

While the importance of health organizations (e.g., hospitals, providers, behavioral health providers, insurers, and health departments) engaging with CBOs as partners is increasingly recognized, these relationships are still taking shape in many communities. As a result, comparatively little is known regarding the essential characteristics of successful models. The innovative and often complex nature of these relationships underscores the need to elucidate the financial, operational, cultural, and strategic considerations that can contribute to success for all parties involved – individuals and their families, the communities being served, CBOs, and health care providers. Key elements and competencies for exploration include:

• CBO organizational traits including governance, business strategy, marketing expertise, financial controls, access to capital for expansion, and leadership and management competencies;
• Partnership mechanisms including any formal or informal agreements;
• Efficient workflows between the organizations to ensure that patient needs are addressed with minimal disruption to both organizations and their workforces;
• Information systems infrastructure to share patient information and coordinate care, as well as facilitate client billing;
• Monitoring capacity to measure partnership success through systems that collect, organize, and communicate data about health, economic and quality of life outcomes; and
• Sustainable financing models such as per-service payments, Medicaid reimbursement, and shared risk arrangements.

The Partnership for Healthy Outcomes: Exploring Successful Models

The Nonprofit Finance Fund, the Alliance for Strong Families and Communities, and the Center for Health Care Strategies are collaborating with support from the Robert Wood Johnson Foundation to capture emerging best practices behind successful health care organization and CBO partnerships. The project, Partnership for Healthy Outcomes: Bridging Community-Based Human Services and Health Care, is issuing a Request for Information (RFI) to uncover core elements and critical success factors from diverse partnership models that serve low-income and other vulnerable populations. Information collected through the RFI will be used to develop case studies, a best practice brief, and other resources that will be disseminated nationally.

Make Your Voice Heard: Share your Experiences in a Brief Survey

CHCS invites representatives from CBOs and health care organizations to share information about their partnerships through the RFI survey. Responses will help: (1) identify promising models and challenges for building effective partnerships; (2) inform funding and policies; and (3) advance effective partnerships across the nation. This is an important opportunity to contribute to the future of these emerging partnerships and their role in improving health outcomes.