The big picture for this special issue: The state of the field, article highlights, and a look into the future

The articles in this special issue are timely. Each discusses a matter of critical importance to an emerging field united by the goal of aligning healthcare, public health, and social services in an otherwise deeply fragmented national and international context. In this commentary, we describe the state of this emerging field, highlight some of the insights in this special issue that may help move the field forward, and then outline several features of this field that are coming into focus as we look at the years ahead.

1. STATE OF THE FIELD

The last 5 years have been a challenging but productive period for local, state, and national efforts in which people and organizations in public health, healthcare, social and human services, and other domains work together. During this time, it has become more common for multi‐sector efforts to have features that support the different systems to cooperate and operate in alignment with one another beyond the period of a temporary grant‐funded project. ¹ It has also become more common for these efforts and models to designate health equity as their purpose or as an outcome of interest. ² These changes are happening across a wide range of contexts, geographic levels of coordination, and focus areas. ³

1.1. Health collaboratives in cities, regions, and states

While many of these arrangements are homegrown in communities or regions, such as Camden New Jersey's Camden Coalition, ⁴ much of the spread of partnerships in which public heath, healthcare, social and human service systems, and often other systems are coordinating and trying operate in greater, sustained alignment with one another has been happening though initiatives based in state government that are led and implemented in local regions, such as Washington's Accountable Communities of Health and Rhode Island's Health Equity Zones. ⁵ , ⁶ Further, in at least two states we see philanthropic organizations supporting approaches that enable healthcare, social services, public health and other sectors to align in multiple regions–in the Texas Accountable Communities for Health Initiative and the California Accountable Communities for Health Initiative. ⁷ , ⁸ The Funders Forum for Accountable Health has been tracking statewide and local partnerships involving healthcare, public health, social services and other systems that have features expected to make those organizations' relationships more sustainable, and their inventory that has been growing and now has over 150 different community or regional examples. ⁹ , ¹⁰

We can expect more examples in the next few years. The Centers for Medicare & Medicaid Services' recently announced Advancing All‐Payer Health Equity Approaches and Development (AHEAD) model which embraces and advances a vision for better coordination and greater alignment among healthcare, social services, and public health systems. ¹¹ The states that participate in the model could expand their current support for systems alignment in service of equitable health outcomes.

1.2. Areas of focus

Many who are pursuing partnerships and coordination that help align healthcare, public health, and other systems to local priorities are driven by specific reasons. The importance of community trust and power especially has become more widely recognized, ¹² and partnerships among healthcare, public health, and social services are including and supporting grassroots, trusted community‐based organizations as well as community members, especially those who experience the effects of inequitable systems.

Community members are joining or reshaping collaborative arrangements not only as informants but as partners and leaders who participate in decision‐making as a part of governance structures for coordinated, aligned systems. ¹³ Using approaches to leadership and governance that are distributed and inclusive of trusted community‐based organizations and community members is a trend that seems likely to support equity and greater trust from the community in systems that support their health. ¹²

2. HIGHLIGHTS FROM THE ARTICLES IN THIS SPECIAL ISSUE

As partnerships like those mentioned above continue to emerge and develop, there have been calls for continuous improvement, monitoring, and learning about better ways to bring partnerships together and, ultimately, meet community needs related to health and health equity. ¹⁴ To help organize research emerging in this field, Glenn Landers and his colleagues from the Aligning Systems for Health project have, in partnership with the Robert Wood Johnson Foundation, presented the Framework for Aligning Sectors. ¹⁵ , ¹⁶ Many of the papers in this special issue build explicitly on this framework (see Figure 1 below).

FIGURE 1.

The Framework for Aligning Sectors (Source: The Georgia Health Policy Center and the Robert Wood Johnson Foundation, Aligning Systems for Health). ¹⁵

The purpose of the Framework for Aligning Sectors is to promote systematic thinking on how collaboratives involving health care, public health, and social service sectors can best improve health equity, racial equity, and community‐defined defined outcomes. Key features of the framework include the following: consideration of context, a shared sense of purpose, shared governance, shared data, shared finance, community voices, trust, power dynamics, equitable processes, changes in practices, changes in mindsets, changes in policy, health equity, racial equity, and community goals and needs. The underlying idea of the framework is that health collaboratives involving public health, health care, and social service organizations will be better able to achieve intermediate and long‐term outcomes with by developing and employing thoughtful strategies addressing their context, shared systems, and relationships with internal and external partners. The framework is presented here because it may be helpful for readers as they read and reflect on the articles in this special issue. As we draw out key highlights below, we will also point out the links to the elements of the framework.

2.1. Meeting community needs

Fleming and colleagues offer a vivid example of the potential of cross‐sector collaboration to bring needed services together and keep them together. They interviewed 31 organizational managers and case managers in a cross‐sector health collaborative in Contra Costa County, California, right at the end of peak 2020 COVID‐19 lockdowns. ¹⁷ The interviewees stated that recent investments in collaboration across‐sectors improved the county's ability to respond to the pandemic. Specifically, participants in the study felt that the county's COVID‐19 response was aided by a culture of adaptability, a network of relationships, improved analytics abilities, and community‐oriented frontline staff – all of which had been put in place during earlier efforts to collaborate across sectors. This work, alongside earlier research that identifies benefits from cross‐sector collaboration using national surveys, highlights the potential for significant benefits from cross‐sector health collaboration. ¹⁸

Creel and colleagues found that collaboratives in different contexts can adapt and meet community needs in different ways. ¹⁹ Their study includes a network analysis of collaboratives in rural and urban Kentucky serving pregnant and parenting women in substance abuse recovery. With fewer service organizations in the rural context (in absolute terms), the rural collaborative clustered around a local hospital, whereas public health agencies played a more prominent role in the more organizationally diverse urban context. Such adaptations demonstrate the ability of collaboratives to balance resources and responsibilities while navigating the opportunities and challenges of different contexts.

2.2. Community voices

Several articles here discuss engagement with community leaders, marginalized community members, and other members of the communities most affected by the collaborative work. Each identifies opportunities to advance this work. Puro and colleagues draw on a survey by the American Hospital Association and find that, compared to private or for‐profit hospitals, public and non‐profit hospitals tend to have a wider range of hospital‐community partnerships and deeper relationships within those networks. ²⁰ Accordingly, private and for‐profit hospitals, as well as the people they serve, may be missing out on the benefits of community voices that can offer information on community needs or ideas for tackling mutual pain points such as those associated with high emergency room usage for non‐emergencies.

The same may be said for whole collaboratives. Angus and colleagues draw on surveys and interview with members of several collaboratives in California's Accountable Communities of Health Initiative and find that people in several collaboratives thought that previously marginalized community voices could be brought into the work better in the future. ²¹ van der Broek‐Altenburgyes and colleagues found that collaboratives in one Vermont initiative tended to prioritize local needs and voices, but they sometimes shied‐away from programs targeting racial and ethnic minorities when other opportunities with high potential for community change were available. ²²

2.3. Sharing data and making connections

Much of a collaborative's value comes from its ability to link services, and several papers here explore the challenges and successes different programs encountered in such efforts. First, the study by Giron and colleagues draws on a survey of Federally Qualified Health Centers to describe nationwide uptake of a standardized screening tool designed to identify patient needs that could be addressed by outside partners. ²³ They find that multiple language options stand out as a factor boosting the usage of the screening tool, underscoring the importance of incorporating community voices in the context of data systems. Second, Fichtenberg and colleagues walk readers through the ups‐and‐downs of a fraught effort to design and implement a user‐friendly electronic community resource referral system. ²⁴ Finally, in a national study of agencies implementing nurse‐family partnerships in the United States before, during, and after the 2020 COVID‐19 lockdowns, Williams and colleagues find that the implementation of telehealth services boosted increased coordination in some issue areas including women's care, even while coordination was falling in other focus areas such as parenting programs. ²⁵ Readers who have had difficulty with the uptake of shared data and systems like these will be interested in all three papers.

2.4. Funding and finance

Taking action is only part of the challenge. A great deal of service work is contingent on funding, and incentives can be an important motivator. This rings true in health collaboratives as much as anywhere else. Hoornbeek and colleagues discuss some of the shared finance incentives their interviewees see as supporting sustainability in cross‐sector health collaboratives, including non‐fiscal incentives, value‐based incentives, and government‐funding incentives. ²⁶ Financial sustainability may also be promoted through economies of scale, as suggested in the paper by Cohen and colleagues. ²⁷

At a systems level, Hemming and colleagues look at the recent American Rescue Plan Act and find is that the social determinants of health can be used to understand such funding policies. ²⁸ Importantly, they suggest that the social determinants of health could also be used to structure or create funding policy in the future. Policy explicitly mapped to the social determinants of health may improve funding accessibility for cross‐sector health collaboratives addressing one or more of the social determinants, especially smaller partnerships with fewer funding navigation resources. ²⁹

2.5. Health equity

At the heart of much of this work is the desire to achieve health equity and build new structures and systems that contribute to health, healing, and well‐being. Several articles in this special issue explore ways to do this. In one example, Piper and colleagues draw on over 80 interviews and focus groups to highlight several approaches their respondents identify as advancing health equity through community partnerships including the following: providing quality education, amplifying community voice in decision‐making, modifying daily operations to be more equitable, and focusing on equitable access and delivery of services. ³⁰ In another paper from this issue, Scott and colleagues highlight the challenges of building the partnerships needed to build community health and health equity. ³¹ Some of the challenges include funding, turnover, and competing priorities. These insights challenge us to refocus our work and develop a deeper understanding of the mindset, policies, and practices that impact health equity.

3. LOOKING INTO THE FUTURE

Much of the recent work in this field builds on the Aligning Systems for Health project, which was led by the Georgia Health Policy Center, supported by the Robert Wood Johnson Foundation, and strengthened by contributions from practitioners and researchers far and wide, including many of authors of this special issue. Recently, the Robert Wood Johnson Foundation created a follow‐on initiative to pursue a deeper understanding of the mechanisms of change for health equity. This initiative is called Aligning for Equity and features a new partnership between the Georgia Health Policy Center and the Institute for Women and Ethnic Studies (IWES).

IWES is a national nonprofit health organization that creates initiatives to heal communities, especially those facing adversity. IWES firmly believes in the power of community to contribute to its health, healing, and well‐being and that true change happens when community becomes the mechanism of change. Communities themselves must become the catalysts for transformation to heal toxic injuries from historic and contemporary experiences of structural inequity. Centering healing in a health equity framework extends the concept of the social determinants of health to acknowledge the impact that systems of oppression have on a community's ability to cultivate healing, maintain health, and extend its members' lifespans and quality of life.

Increasingly, institutions are being called upon to be accountable to communities when it comes to authentically sharing power over health funding, data, and other factors affecting health equity. By moving beyond the tendency to incorporate community voice into existing processes and dynamics that are inherently inequitable, systems can build the collective muscle for community‐led change that directly addresses the mindsets, policies, and practices that perpetuate health inequities and fragmented systems of care.

Acknowledging the devastating impacts of injustice is the foundation of equity work. To improve health outcomes, institutions must go further and take steps to change their practices and share power with those most affected by systemic oppression. IWES is dedicated to creating spaces for meaningful engagement that prioritize cooperation, cross‐sector collaboration, and flourishing together.

To help advance such work in their own communities, readers can draw on the articles in this special issue for a wide range of insights on aligning health care, public health, and social organizations to address the goals and needs of people and communities they serve. Readers may also find ways to contribute their own findings to the broader field. For example, many of the programs featured in this special issue are in their early stages, and their impact on health outcomes and health equity has not been systematically measured. It will be important for future work in this space to involve an assessment of health outcomes and contribute to what the field knows about how to improve those outcomes.

The work in this special issue will be useful to both practitioners and to researchers looking ahead to the critical work of the coming years: understanding and implementing community leadership in health collaboratives, bringing these partnerships to bear on community priorities, improving health equity, and sharing important lessons that may help others do the same.

Minyard K, Heishman H, Lanford D, Richardson L, Shervington D. The big picture for this special issue: The state of the field, article highlights, and a look into the future. Health Serv Res. 2024;59(Suppl. 1):e14266. doi: 10.1111/1475-6773.14266