Social service integration

There is some evidence that integrating social services can improve access to social services (Mantler 2020, Fisher 2012, Mathematica-Cody 2010, MDRC-WASC, Rosenheck 2001) and improve health and health-related outcomes (Brewster 2020, 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, Mosley 2021). Social service integration is also a suggested strategy to reduce service gaps, fragmentation, and duplication (King 2006, Packard 2013), and better serve older adults with serious illnesses (Golden 2019a) or multiple chronic conditions (Brewster 2020). However, additional evidence is needed to confirm effects.

Available evidence suggests integration of clinic and community service systems may decrease health care costs (Brewster 2020, Tschudy 2013, IHI-Craig 2011) and health disparities (Tschudy 2013, Fichtenberg 2020), and increase clinical and community capacity to provide on-site 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 veterans experiencing homelessness (O'Toole 2016). Integrating health services in women’s shelter services may increase service access and satisfaction with services among women who have experienced intimate partner violence (Mantler 2020). 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 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 coordination (CWF-McGinnis 2014, Mitchell 2020a), and cultural awareness and responsiveness among staff (Lucero 2012). 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 efforts (Packard 2013, McCall 2021), while separated budgeting by department appears to impede interagency service integration (McCullough 2020). 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).

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 incomes (ACF-Bowen). 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 incomes (ACF-Bowen). 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 racism (Irwin 2021).

There is some evidence that social service integration has the potential to decrease disparities in health outcomes and service access (Brewster 2020, Mantler 2020, Lucero 2012). Available evidence shows that interagency partnerships can reduce health care spending and improve health outcomes among older adults (Brewster 2020) and increase child well-being and safety for Native American families (Lucero 2012). Integrating health and social services in women’s shelters may increase service access among women who have experienced intimate partner violence (Mantler 2020). 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 housing (Sheppard 2022), individuals with serious mental illness (Golden 2019a, Storm 2020), veterans (Fisher 2012), individuals experiencing homelessness (Mosley 2021, O'Toole 2016), children at risk of food insecurity (Brochier 2022), first-time mothers and young children (Tschudy 2013), and communities affected by poverty and systemic racism (Irwin 2021).

The federal government’s first efforts at social service integration were through the U.S. 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 coordination (Soler 1990, Agranoff 1991). 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 disabilities (Soler 1990). 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 programs (Waldfogel 1997).

• 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 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 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 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-Florissa). 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).

‡ Resources with a focus on equity.

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

RHIhub-Florissa^‡ - Rural Health Information Hub (RHIhub). Models and innovations: Florissa.

* Journal subscription may be required for access.

ACF-Bowen - Bowen R, Hattemer K, Griffin K. Building financial capability: A planning guide for integrated services. U.S. Department of Health and Human Services, Administration for Children & Families (ACF), Prosperity Now. GSA Schedule Contract GS-10-F-0177L; Order No HHSP233201200674G.

Agranoff 1991 - Agranoff R. Human services integration: Past and present challenges in public administration. Public Administration Review. 1991;51(6):533-542.

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.

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.

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

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.

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.

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

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

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.

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.

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

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.

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.

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.

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.

Kenosha-Children First - Kenosha County Child Support Services, Wisconsin. Kenosha County CSA Children First Program.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

RHIhub-Florissa - Rural Health Information Hub (RHIhub). Models and innovations: Florissa.

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.

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.

SEWIWDA 2018 - Southeast Wisconsin Workforce Development Area (SEWIWDA). Workforce lnnovat¡on and Opportunity Act (WIOA) Plan 2016-2020. June 2018.

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.

Soler 1990 - Soler M, Shauffer C. Fighting fragmentation: Coordination of services for children and families. Nebraska Law Review. 1990;69(2):278-297.

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.

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.

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

US DHHS-Children First SHARP - U.S. Department of Health and Human Services (U.S. DHHS). Co-location: Kenosha County’s strategy to move parents to work. Children First SHARP (Supporting Parents, Holistic Case Management, Access to Employment, Reaching Goals, Positive Parenting).

Waldfogel 1997* - Waldfogel J. The new wave of service integration. Social Service Review. 1997;71(3):463-484.