Addressing Social Determinants: Scaling Up Partnerships With Community-Based Organization Networks

As health care payment models become more value-based, health care systems are increasingly interested in approaches that address both medical needs and social determinants of health. 
This isn’t surprising. Services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-medical risk factors have been shown to  improve health outcomes and reduce the cost of care. This is particularly true for “high-need, high-cost” people who have complex health conditions and social risk factors and who often have significant functional limitations.
Integrating these services into health care requires robust planning and assessment, expert knowledge and navigation of a complicated social service system, ongoing case management, and accountability for service delivery and outcomes. Incorporating these services requires health care payers and providers to “build” internal organizational capacity or “buy” it from existing service providers. When making that decision, there are many factors for health care organizations to take into consideration, not the least of which are local factors in the communities and markets they serve.   
For many organizations, however, partnering with the existing infrastructure of community-based organizations (CBOs) in the aging and disability network—buying rather than building—is the more cost-effective strategy for delivering the full continuum of quality care and support for their most high-risk and high-need patient populations. Federal and state governments have made significant investments in this network, which includes over 20,000 CBOs. Since 1965, the network has been a trusted resource, delivering home- and community-based care to one in five of America’s older adults, as well as people of all ages with disabilities.
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