Assessing Equitable Implementation of a Social Care Initiative Integrating Medical and Social Services for Medicaid Members

ABSTRACT

Objective

To assess the equitable implementation of a case management program integrating medical and social services for Medicaid members.

Study Setting and Design

This qualitative study assessed the equitable implementation of a case management program in Contra Costa County, CA. Study participants were identified using purposive sampling. Semi‐structured interviews were conducted in person or by phone.

Data Sources and Analytic Sample

Primary data were collected between Fall 2019 and Spring 2021 and included 92 semi‐structured interviews with patients (n = 31), case managers (n = 47), and county administrators (n = 14). Data were coded using an inductive‐deductive framework analysis approach informed by the Health Equity Implementation Framework (HEIF).

Principal Findings

Characteristics of the innovation influencing equitable implementation included experienced public health nursing leadership and inclusion of social risk factors in a predictive algorithm determining patient program eligibility. Recipient factors included inequitable emotional demands of medical and social service integration work on case management teams from diverse racial/ethnic and training backgrounds, and patient experiences of mistreatment from medical and social service institutions. Clinical encounter factors highlighted the necessity for trust building between patients and case managers and the importance of multidisciplinary expertise to address patients' interconnected medical and social needs. Contextual factors described organizational readiness in the form of multidisciplinary teams with reduced hierarchical power imbalances, system‐wide investments in a universal data infrastructure and data insights team, and strong intra‐ and inter‐organizational partnerships. Societal factors included systemic discrimination and racism, insufficient affordable housing and public transit, pervasive administrative barriers in accessing health and social services, and federal funding for holistic approaches to integrated care.

Conclusions

Case management programs aiming to equitably integrate social and medical services should invest in multidisciplinary case management teams, organizational readiness for equitable implementation via committed, experienced leadership, and interventions to address systemic factors hindering the engagement of historically marginalized groups.

Summary.

• What is known on this topic?

  • ○
    Health systems increasingly use case management programs to align medical and social services and improve outcomes for historically marginalized patients, but limited evidence exists about implementing these programs equitably.
• What this study adds

  • ○
    Few studies have studied the characteristics of case management programs that impact equity for patients and frontline staff.
  • ○
    Investments in multidisciplinary case management teams, data sharing, analytic infrastructure, and interventions to address systemic factors hindering the engagement of historically marginalized groups can promote equity in social care program implementation.
  • ○
    Our application of the Health Equity Implementation Framework can be replicated in research and practice settings to support the equitable design, implementation, and evaluation of case management programs and other healthcare interventions.

1. Introduction

Healthcare delivery in the United States is deeply siloed, both within and across health and social sectors, leading to care fragmentation for patients. Care fragmentation describes medical care for a single patient that is distributed across multiple clinicians, clinics, and/or health systems [1, 2]. To receive quality care, patients are expected to coordinate medical, social, and behavioral health services independently across clinical teams and organizations. The challenge of managing services across several sources of medical care can lead to poorer communication among care team members and with patients, resulting in increased costs, poorer health outcomes, and lower quality care. Patients belonging to historically disadvantaged groups are disproportionately impacted by care fragmentation, especially those with multiple complex conditions, as they face structural and social barriers to care [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. Provision of social care, alongside medical care, in the form of food, housing, and legal services can positively impact health outcomes and potentially help narrow health disparities rooted in generations of racism, systemic exclusion, and classism [11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22]. However, prior evidence illustrates that even well‐intended social care interventions can exacerbate systemic health inequities. This highlights the importance of equitable implementation, or explicit consideration of equity in considering what services are being delivered, by and for whom, and under what conditions [23, 24, 25, 26].

California, as part of its Medi‐Cal 2020 1115 Medicaid waiver, implemented “Whole Person Care” pilot programs between 2016 and 2021 to provide Medicaid members with integrated case management of their medical, behavioral health, and social needs. Health systems nationwide are increasingly adopting this approach to assist patients with navigating historically siloed service systems [27, 28, 29]. While a growing body of evidence suggests that integrated case management can improve access to preventive care and reduce utilization of hospital‐based services [30, 31, 32, 33], limited research has analyzed how these programs may ameliorate or exacerbate health inequity for frontline staff or the marginalized patients they serve. Qualitative studies evaluating these interventions have identified challenges in connecting patients with resources to meet their medical and social needs [34], sharing data, and developing consistent workflows and role definitions across health systems and social service organizations [35, 36]. Prior studies also highlight the importance of a care coordination workforce with lived experiences aligned with patient experiences and establishing strong community partnerships for effective social service delivery [35, 36, 37].

We define health inequities as disparities in access, quality, or outcomes of care based on social position as a result of structural discrimination and racism [38]. In this qualitative study, we aimed to explore how a Whole Person Care pilot in Contra Costa County, California, called CommunityConnect, addressed health equity during program design, implementation, and evaluation. The program offered case management to Medicaid members, coordinating medical and social services across clinical and community‐based settings through in‐person and phone visits. CommunityConnect was successful at increasing members' access to primary care and reducing inpatient hospital admissions [30, 39]. Our analysis of CommunityConnect provides examples of factors that can support or inhibit equity in the design and implementation of social care interventions intended to narrow health disparities.

1.1. Conceptual Framework

Our analysis is informed by the Health Equity Implementation Framework (HEIF), an implementation science framework outlining key domains relevant to the equitable implementation of interventions in healthcare settings. The HEIF is well suited to this analysis given the framework's comprehensive consideration of factors influencing equity for patients receiving and staff delivering interventions in health settings [40, 41]. The HEIF identifies domains in which implementation decisions may influence equity, including characteristics of the innovation; clinical encounters; recipient factors (patient and provider); context factors of the immediate intervention setting; broader organization; and healthcare system; and the societal context. Definitions of each domain are provided in Table 1.

TABLE 1.

Health Equity Implementation Framework domains and definitions.

Domain or subdomain	Definition
Characteristics of the innovation	The characteristics of the innovation domain includes constructs describing the underlying knowledge sources about the innovation, clarity of the innovation to key stakeholders, and the degree of fit with existing practices and values within an organization, among others.
Clinical encounters	The clinical encounters domain describes the interaction between patients and providers, including how the patient and provider identify, tailor, and coordinate their interaction to achieve health goals.
Recipients	The recipients domain describes the knowledge, attitudes, values, beliefs, skills, power, and processes of collaboration among individuals with influence over how an intervention is implemented.
Recipients: providers: & staff	The recipients: provider and staff factors domain describes characteristics of the individuals who influence implementation processes, both at individual and team levels.
Recipients: patients	The recipients: patient factors domain describes the individuals who will receive the intervention and calls out the role of health literacy, medical mistrust, socioeconomic status, cultural norms, and beliefs and preferences in equitable implementation.
Context factors	The context factors domain describes characteristics of implementation within the immediate setting where an intervention takes place. These factors can include the organization's history of innovation or change, senior leadership support for the intervention, team and organizational culture, established processes for internal evaluation and feedback, and inter‐organizational networks related to implementation.
Inner context: local	The inner context: local domain describes factors related to implementation within the immediate setting where an intervention takes place. These factors can include previous experiences implementing innovations or other changes, formal and informal leadership support, team culture, and established processes for internal evaluation and feedback.
Inner context: organizational	The inner context: organizational domain includes constructs pertaining to the organizational atmosphere in which the unit or team is embedded, such as organizational priorities, organizational culture, the organization's history of innovation or change, learning networks, absorptive capacity, and senior leadership and management support for the intervention.
Outer context: healthcare system	The outer context: healthcare system domain describes the broader context surrounding the implementing organization, including factors such as national policy priorities, incentives and mandates, regulatory frameworks, external accreditation systems, and inter‐organizational networks related to implementation.
Societal context	The societal context domain describes influences beyond the healthcare system that could impact each of the other domains. These influences might include local, state, and national economies, physical structures in the geographic region where an innovation is implemented, and local and national sociopolitical forces.
Economies	The economies domain describes characteristics of traditional, command, market, and mixed economies pertaining to human and nonhuman resources needed to access healthcare and health insurance.
Physical structures	The physical structures domain describes the built environment where recipients of the intervention live, as well as the physical structures surrounding the organizations providing services. This pertains to the historical and ongoing segregation of communities of color, differential access to parks, transportation, grocery stores, hospitals, and other structural resources.
Sociopolitical forces	The sociopolitical forces domain describes informal and formal policies and procedures enforced by local and national governments that systemically impact equitable health outcomes. These laws, cultures, or policy climates can also perpetuate or combat racism, classism, heterosexism, and transphobia, among other forms of discrimination.

A conceptual framework integrating core CommunityConnect program components with HEIF domains is outlined in Figure 1.

FIGURE 1.

Conceptual framework integrating core CommunityConnect program components with Health Equity Implementation framework domains.

2. Methods

2.1. Study Design

We used an in‐depth qualitative study design to investigate factors contributing to the equitable implementation of CommunityConnect. Qualitative interview data assessed patient, case manager, and administrator perspectives regarding implementation. The HEIF was used to analyze the extent to which CommunityConnect (1) ensured equitable access to medical and social services for patients; and (2) equitably distributed implementation demands on and support for staff, with a specific focus on historic and systemic influences on trusting relationships, power structures, and investments to advance equity [42].

2.2. Setting

CommunityConnect began offering integrated case management services for social and medical care needs to Medicaid members in Contra Costa County, CA, in 2017. The program was implemented by Contra Costa Health, the county's safety‐net healthcare system, which includes multiple clinics, a single hospital, the public health department, and a local Medicaid Managed Care Plan covering the majority of the county's Medicaid members [30].

Eligible Medicaid members were identified using a risk‐based, predictive algorithm that considered chronic disease diagnoses, prior service utilization, and social risk factors. Case managers reached out telephonically to invite members to participate and used an internally developed tool to screen for patient needs and establish goals. Case management activities, conducted via phone or in‐person based on member acuity, included medication management, health goal setting, support in scheduling medical and social services appointments across multiple organizations, benefits application support, and psychosocial support. Patients could also be provided a mobile phone, legal aid, and transportation and housing vouchers. The program served approximately 12,000 patients at a time [30].

Contra Costa County was one of 25 Whole Person Care pilots (representative of 25 counties and one city) in California. Contra Costa County's pilot was selected for this analysis given its explicit focus on equity in program design and implementation and the diversity of patients served by the program (31% White, 29% Latinx, 24% Black or African American, and 9% Asian American or Pacific Islander) [30].

2.3. Data Collection

Semi‐structured interviews were conducted in two waves. In Wave 1 (2019), Contra Costa Health internal evaluation team members interviewed a convenience sample of case managers and patients. Interviews ranged from 60 to 90 min and were conducted by six evaluators trained in qualitative methods, all women between the ages of 25 and 40 years. Three interviewers identified as Latino, and three as White. At Wave 1, 33 case managers providing in‐person services with > 1 year of experience with CommunityConnect were invited for interviews and 30 participated. Interviewed case managers recommended patients actively enrolled in the program, who participated in 15–30 min interviews. In Wave 2 (2020–2021), two university‐based researchers conducted interviews with case managers and administrators (30–60 min long). Wave 2 interviews were conducted by phone due to coronavirus pandemic restrictions, and interviewers identified as White (n = 1) and mixed‐race (n = 1) women aged 25–40 years. Interview participants in Wave 2 were selected using purposive sampling across key stakeholder role types. All interviews were audio recorded and transcribed verbatim. Interview guides are available upon request.

2.4. Analysis

Interview transcripts were coded in NVivo (QSR International Pty Ltd. 2022, version 12) using an iterative inductive‐deductive framework analysis approach informed by a critical, post‐positivist perspective. The analytic team collaboratively constructed a codebook of a priori codes structured around the HEIF with codes for each HEIF domain. Inductive codes were defined and added to the codebook during early stages of analysis. Refined themes identified through analysis were validated using a consensus approach [43]. Differences in data interpretation were also resolved using a consensus approach [44].

Research methods were approved by the Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (protocol 12‐17‐2018).

3. Results

We conducted a total of 92 interviews with patients (n = 31), case managers (n = 47), and administrators (n = 14) (Table 2). Among patients, interviewees were diverse in terms of age and race/ethnicity, and among case managers, interviewees represented all case management disciplines involved in CommunityConnect.

TABLE 2.

Interview participant demographics.

	Wave 1 (Spring 2019 to Fall 2019)	Wave 2 (Fall 2020 to Spring 2021)	Total both waves
Patients—overall	31	0	31
By age group
20 to < 40	4		4
40 to < 60	12		12
60 and older	15		15
By race/ethnicity
Asian	2		2
Black/African American	5		5
Hispanic/Latino	5		5
White	13		13
Other or not stated	6		6
Case managers—overall	30	17	47
Public health nurse	9	5	14
Substance use counselor	5	2	7
Community health worker	2	4	6
Social worker	6	1	7
Mental health clinician	4	3	7
Homeless services specialist	4	2	6
Administrators—overall	0	14	14
Total all interviewees	61	31	92

Results that follow are presented by the HEIF domains influencing equitable implementation. Key findings by domain, as well as demonstrative quotes for each finding, are presented in Table 3.

TABLE 3.

Key findings and demonstrative quotes by HEIF domain.

HEIF domain	Key findings	Demonstrative quote
Characteristics of the innovation	Use of a predictive algorithm incorporating social risk factors to identify eligible patients may have contributed to inequitable access to resources	“If [people] never hit our health system, then they're not going to show up in our risk model. And there's definitely several thousand of those individuals in our communities…Because everybody that hits our risk model has full scope Medi‐Cal…There's a big percentage out there that's never hit our system that definitely would be able to take advantage of the services we provide.” Administrator 05
Recipients	Case management staff brought diverse lived experiences and racial/ethnic backgrounds and shouldered the emotional demands of case management work with minimal organizational supports	“The type of work we do… at times it's really, very difficult because it's very emotional and very you know it's very time consuming…I think sometimes maybe upper management isn't really understanding exactly what entails on these home visits and what we're walking into and what we're seeing and what's really going on and so I think that's a missing component of really understanding and supporting us as employees because we don't want to feel like we're not being heard and we're burnt out and our work is not really you know really valued in a sense.” Case manager 15
	Patients' prior care experiences with medical and social services influenced their perceptions of CommunityConnect	“I thought county help was that old picture of the ‘70s in the projects’, you know? With the big building and even though you're in there, you're still poor and that's what county help was to me, you know and now I'm seeing that it's not, it's actual real help.” Patient 09
Clinical encounter	Meeting patients “where they were at” helped build trust up front to center patient needs and goals, facilitating successful interactions	“It was one of the first things. I was talking to her in passing and I was like, ‘Oh I need to get my glasses’. I go, ‘I can't pay for the frame and lenses, they're expensive…She's like ‘I can help you with that’… so that was one of the first things that she helped me with and I guess that kind of built confidence you know, with her and trust. And she was just always open, understanding, and that's why you know, I stuck with the program.” Patient 09 “She lets me know. ‘You want to do this? You want me to sign you up?’ I say either yes or no. She doesn't ever say, ‘Well you should’, or ‘You shouldn't’, never. Whatever I want to do to. That's what I love about her, her honesty and she lets me know what my options are. And if I don't want any of her options, she doesn't contrary with me, she doesn't you know, like look down at me. She says, ‘Okay we are trying to do what we can for you’” Patient 12
Multidisciplinary expertise supported a tailored, holistic approach to addressing patients' interconnected social and medical needs	“I think that was where, that kind of project that we had done had really informed how we constructed the care teams and the case management model, which was more of a model of having multiple types of disciplines so that people could pull on the different skillsets that could address the drivers for different people. Whether it be a mental health clinician, whether it be a substance use disorder [specialist], whether it be [addressing] chronic debilitating illness, physical illness, whether it be access to needs and social services. That was the idea behind having an interdisciplinary group of case managers who could all support the people that we were serving with their specific needs.” Administrator 12
Context factors	Prevention‐focused public health nursing leadership championed equitable program design and implementation for patients and frontline staff by shifting power dynamics within teams and emphasizing a cross‐sector approach	“The challenge was saying to people like, ‘You've got to trust that this model works,’ because there was a lot of people that didn't believe it. They've never done the work. They don't understand a public health model, and they're just, like, going, ‘Oh, no, that's not going to work,’ or, ‘You've got to do this,’ and then they would kind of climb down on us, but there was enough of us in public health to just keep pushing that saying, ‘No, it's a process. Let's get everyone trained. It'll start happening, and it'll start coming together.’” Administrator 08 “When we were first formulating the core group of services that we were delivering, and we were trying to construct this model that was, no matter what your discipline and training is, everyone is a CommunityConnect case manager, and what does that mean? That means that you have to address this core group of services, even if that's not something that you see as your usual in your lane.” Administrator 12 “Another big aspect to our program is that we are so multi‐disciplinary under one roof…I have never had such immediate access to other specialties before. That we are all working here together. It's amazing because when I do have someone medically fragile, I can turn around to a co‐worker who is trained in that field and ask, ‘What is this diagnosis? What does this medication treat?’ when I'm reading someone's chart. Then they can ask me for resources also. That immediate access is designed as a system that needs to stay in place. Without it our jobs would be a lot harder.” Case manager 03
System‐wide investments in a universal data infrastructure, dedicated analytics staff, and internal evaluation team allowed for adaptations to support equitable implementation	“Our health department [is] somewhat unique because we have one organization which includes hospital and clinics or a public health department, behavioral health, [emergency medical services], and all that…So, all the data resides in a data warehouse and we have this unique vantage point because, you know, we see all the data. We work with every division.” Administrator 04
Strong collaborative relationships with internal and external partners supported equitable implementation by filling gaps in organizational expertise and resources	“We've built more than we've subcontracted or bought… but we do have a couple of big [partnerships with] a couple of clinic systems… [and] the relationships with them have been key because some of the most affected communities trust them the most… because those organizations are super community oriented and are trusted by some of the people that we most need to reach.” Administrator 01
Societal context	Local physical structures, including the affordable housing crisis in the Bay Area and inefficient public transit options, led to creative workarounds for patients, especially those who are most marginalized	“CommunityConnect was able to support them with…the first month's rent and the deposit and they were able to move in. I was able to work with a landlord who I still have a relationship with…and CommunityConnect was also able to support with some furniture as well, so this [patient] left from being in a shelter to being placed in her own apartment [with her family].” Case manager 25 “Transportation, I don't know if that was a super big thing we thought through—and that continues to be an ongoing issue. One of the major concerns that people have is that they can't get to places because they don't have transportation and it's not easy for them to get it. And so, [patients say] ‘It's easier to call 911 and have the ambulance transport me because I don't have any other way to get there’.” Administrator 02
Administrative barriers to Medicaid and social service access and eligibility posed challenges for most patients and case managers seeking to support them	“I'm not that good at computers, not my thing—I know. But [my case manager] is just able to start mapping out letters [to apply to social services], and she know who to go to. Who to write to. Who to say what to. When she showed up to my appointment with me to Doctor XX. Your badge does speak a lot of words and it does. You wouldn't believe how much it does…To have someone have my back… It just, it takes a lot of stress off you.” Patient 30 “This whole group of people who are… the most marginalized and the most unstable are the people that are sort of cycling in and off of Medi‐Cal…If we end up serving only the people that manage to be stable enough that they maintain their benefit and a managed care plan, our concern is that we're going to miss addressing the group that we're trying to stabilize and get to that place.” Administrator 12 “[Cell phones] were not things that were originally in the [CommunityConnect] package…we figured out that in order to take good case management our patients needed to have a phone…We started working with [a cell phone provider], kind of refiguring all of that out. How do we get them phones that are essentially smart phones so they can start to learn how to use them, and then how do we, you know, transition them into a way that they can sustain having a phone?” Administrator 03
Federal funding was viewed as imperative for program implementation and sustainability	“I think, for a lot of the [program's] partners, this was a whole new, and I guess it is true, that was the whole point of the project, from the fed level and the state level, is that they were funding things that had never before been funded within the context of public health services. It was an opportunity for a lot of that to finally be able to address what we knew to be the core issues contributing to people's welfare.” Administrator 12

3.1. Characteristics of the Innovation

3.1.1. Identifying Eligible Patients Using a Predictive Algorithm

CommunityConnect used a predictive algorithm to determine patient eligibility for case management services. To enhance equity, an in‐house analytic team included variables indicative of social risk factors in the algorithm, such as zip code and socioeconomic status, in addition to patient demographics, utilization, clinical diagnosis, and behavioral factors [30]. However, one reported weakness of this approach was that the algorithm weighted utilization more heavily than social or structural factors and was thus still perceived as contributing to inequitable access to resources for certain populations.

3.2. Recipients of the Innovation

3.2.1. Case Management Staff Brought Diverse Lived Experiences and Racial/Ethnic Backgrounds

CommunityConnect deliberately hired case managers with diverse lived experiences and racial/ethnic backgrounds concordant with those of Medicaid members. Administrators and case managers reported that concordant lived experiences or racial/ethnic backgrounds between case managers and patients enhanced connection and empathy in case management sessions. Case managers reported feeling deeply invested in their work, some electing to work additional hours without pay to support their patients. They also shared that their daily work required witnessing stories of suffering and trauma, sometimes in settings that could be harmful to their physical safety and health. Although case managers reported persistent and lingering impacts of the work on their physical and mental health, few cited organizational supports or resources available to help manage these impacts.

The type of work we do… it's really, very difficult because it's very emotional and very… time consuming…I think sometimes maybe upper management isn't really understanding exactly what's entailed on these home visits and what we're walking into and what we're seeing and what's really going on and so I think that's a missing component of really understanding and supporting us as employees because we don't want to feel like we're not being heard and we're burnt out and our work is not really you know really valued in a sense. Case manager 15

In particular, case managers with concordant lived experiences (e.g., former substance use and homelessness) were described as bringing critical, additional compassion and skills to their work. Concordant lived experience was perceived as important for enhancing equitable access to and engagement in case management for patients, but it was also seen as placing inequitable, increased emotional burden on case managers.

3.2.2. Patients' Prior Care Experiences Influenced Perceptions of CommunityConnect

Patients participating in CommunityConnect shared varied perceptions of and trust in the program. Some patients reported immediate comfort with their case manager and with the services offered, while others shared concerns about being judged for their substance use, homelessness, and literacy level. Several patients also shared negative past experiences with healthcare or county systems as a result of their socioeconomic status, race, or other lived experiences, which in turn negatively impacted their initial trust and engagement with the program.

I thought county help was that old picture of the ‘70s in the projects, you know?’ With the big building and even though you're in there, you're still poor and that's what county help was to me, you know and now I'm seeing that it's not, it's actual real help. Patient 09

3.3. Clinical Encounter

3.3.1. Meeting Patients “Where They Were At” to Facilitate Successful Interactions

Case managers described meeting patients “where they were at,” both geographically and psychologically, as critical for equitable implementation for patients. For some, this meant meeting and developing relationships with patients in freeway underpasses, shelters, and shared homes where they lived rather than in “traditional” healthcare settings. For many case managers, these interactions also involved providing patients with not just service coordination, but emotional support. In the exact words of multiple case managers, “patients just want to be heard,” and providing a listening ear often signified a successful, trust‐building early interaction with a patient even if other services were not provided. To earn patient trust, case managers also reported focusing on first supporting patients in accessing basic needs (e.g., food, a cell phone, and transportation) before addressing other long‐term goals. As one patient reported:

It was one of the first things. I was talking to her in passing and I was like, ‘Oh I need to get my glasses’. I go, ‘I can't pay for the frame and lenses,’ they're expensive…She's like I can help you with that… so that was one of the first things that she helped me with and I guess that kind of built confidence you know, with her and trust. Patient 09

Patients shared that case managers' persistent, nonjudgmental outreach and commitment to honoring patient preferences supported trust‐building and encouraged sustained engagement. As one patient reported:

[My case manager] lets me know. ‘You want to do this? You want me to sign you up?’ I say either yes or no. She doesn't ever say, ‘Well you should’, or ‘You shouldn't’, never. Whatever I want to do to. That's what I love about her, her honesty and she lets me know what my options are. And if I don't want any of her options…she doesn't you know, like look down at me. She says, ‘Okay we are trying to do what we can for you’. Patient 12

3.3.2. A Holistic Approach to Addressing Patient Medical and Social Service Needs Relies on Multidisciplinary Case Manager Expertise

CommunityConnect patients often had complex and interdependent social and medical needs. One administrator described how CommunityConnect deliberately included case managers with distinct disciplinary expertise (e.g., in housing, behavioral health, public health nursing, community health work, and substance use coaching) to effectively support patients:

The case management model… had multiple types of disciplines so that people could pull on the different skillsets that could address the drivers for different people. Whether it be a mental health clinician, whether it be a substance use disorder [specialist], whether it be [addressing] chronic debilitating illness, physical illness, whether it be access to needs and social services. That was the idea behind having an interdisciplinary group of case managers who could all support the people that we were serving with their specific needs. Administrator 12

Patient‐reported experiences affirmed the need for multidisciplinary expertise, describing case managers' support in navigating multiple federal and local social service systems as well as medical care access, including establishing relationships with and scheduling primary and preventative care (e.g., cataract surgery and dental), sometimes after years without care. Some patients also highlighted case managers attending medical visits with them to advocate for their needs. For patients whose primary language was not English, with reduced vision, or with limited literacy, case managers were described as playing a critical role in facilitating medical and social service access.

3.4. Context Factors

3.4.1. Experienced Public Health Nursing Leadership Guided Equitable Program Implementation and Shaped Case Management Team Training, Culture, and Hierarchy

Nearly every administrator emphasized the importance of experienced, public health nurse leaders for equitable implementation of CommunityConnect. These nurse leaders were described as having a demonstrated commitment to equity, an unwavering focus on holistic efforts to promote health, and extensive experience designing, implementing, and scaling large prevention‐based interventions like CommunityConnect. This was perceived as essential to meeting the demands of “flying a plane while building it” during the early stages of the program.

The nurse leaders were also credited with developing a team culture that emphasized the assets of multidisciplinary individuals to address patients' complex and interrelated needs, and successfully navigate traditional, siloed‐by‐role models of healthcare and social service delivery within the county. Program administrators tried to “break down” existing power structures by purposely uniting team members from the county's health system (e.g., public health nurses) and various public health departments (e.g., employment and human services specialists, behavioral health) to support a holistic approach to meeting patients' social and medical needs. In an additional effort to break down role‐based siloes, the program's nursing leadership also required that case managers be cross‐trained so that each case manager had some knowledge of their teammates' expertise:

When we were first formulating the core group of services that we were delivering, we were trying to construct this model that was, no matter what your discipline and training is, everyone is a CommunityConnect case manager, and what does that mean? That means that you have to address this core group of services, even if that's not something that you see as your usual in your lane. Administrator 12

Case managers reported that this approach allowed for relatively flat team structures that helped foster collaboration and psychological safety within the team when questions or challenges arose [45]. As described by a case manager:

Another big aspect to our program is that we are so multi‐disciplinary under one roof…I have never had such immediate access to other specialties before. That we are all working here together. It's amazing because when I do have someone medically fragile, I can turn around to a co‐worker who is trained in that field and ask, ‘What is this diagnosis? What does this medication treat?’ Case manager 03

3.4.2. Prior System‐Wide Investments in a Universal Data Infrastructure

A strong business insights team, established years before implementation, integrated multiple data streams across county departments into a centralized database, customized the operability of their electronic health record to include features supportive of case management, and strengthened analytic capabilities across departments through stakeholder‐engaged workflows informed by human‐centered design strategies. Nearly every administrator referenced the importance of this team in conducting rapid cycle testing with frontline supervisors and staff to adapt services in ways that supported equitable implementation for patients. Additionally, the centralized database was reported to support case management efforts and reduce case manager documentation burden, as most patient medical and social service data could be accessed across teams and departments without the need for repetitive data entry across disparate data management platforms:

Our health department is somewhat unique because we have one organization which includes hospital and clinics or a public health department, behavioral health, EMS, and all that…So, all the data resides in a data warehouse and we have this unique vantage point because, you know, we see all the data. We work with every division. Administrator 04

3.4.3. Inclusion of Patient and Staff Voices in Formative and Process Evaluations

Internal program evaluation supported equity by inviting patients and staff voices to provide input during implementation. Feedback was most often captured informally during patient‐case manager interactions, team meetings, or one‐on‐one check‐ins with supervisors. Program evaluators also collected these stakeholders' feedback formally over 5 years. Patient and staff feedback informed changes to program design (e.g., offering eligible patients free cell phones) to support equity for both stakeholder groups.

3.4.4. Strong Collaborative Relationships With Internal and External Partners

Strong relationships with local federally qualified health centers, other departments within the county, and community‐based organizations were reported as integral to equitable social and medical service delivery by filling gaps in organizational expertise and resources. Administrators shared that while they opted to strengthen internal capacity (e.g., hiring staff and building out internal infrastructure) as much as possible, community partners filled gaps in certain areas of expertise (e.g., legal services, food access, and housing) and outreach to specific populations:

We've built more than we've subcontracted or bought…but we do have a couple of big [partnerships with] a couple of clinic systems… [and] the relationships with them have been key because some of the most affected communities trust them the most… because those organizations are super community oriented and are trusted by some of the people that we most need to reach. Administrator 01

Whereas some patients found outreach from county‐branded staff intimidating or confusing, initial outreach from trusted community‐based organizations, especially those with culturally‐ and language‐concordant staff, was more effective. Financial incentives available through the Medicaid waiver were described as essential for establishing and sustaining community partnerships with resource‐constrained community‐based organizations, as these incentives allowed for some remuneration for partner engagement, supporting equity.

3.5. Societal Context

Participants described the structural characteristics of local and national social institutions and the built environment that informed the design or operation of CommunityConnect as impacting equity.

3.5.1. Historic and Ongoing Discrimination and Racism in the United States' Medical and Social Systems Led to the Erosion of Patient Trust in County Services and Outreach

Case managers acknowledged systemic racism and discrimination against historically marginalized groups by both healthcare and county systems as decreasing patient trust in these systems and, initially, negatively impacting enrollment and engagement with CommunityConnect. Patients echoed the influence of these systemic factors on their participation and engagement in CommunityConnect, and both case managers and patients highlighted the importance of consistent, nonjudgmental relationship building to address patient histories of mistreatment.

3.5.2. Lack of Affordable Housing and Inefficient Public Transit Options Led to Creative Workarounds

Lack of affordable housing was a primary structural inequity referenced in interviews across participant types. Case managers and patients noted the lack of physical space for affordable housing in Contra Costa County, creating a “housing crisis” accompanied by high rent costs and up‐front expenses of securing housing, including security deposits and basic necessities. Administrators highlighted the importance of partnerships with internal county partners, like the housing department, in providing needed expertise and connections to local landlords with available housing. Unrestricted Medicaid waiver funds also supported a housing fund to bridge the gap in affordability for patients, as noted by one case manager:

CommunityConnect was able to support them with…the first month's rent and the deposit and they were able to move in. I was able to work with a landlord who I still have a relationship with…and CommunityConnect was also able to support with some furniture as well, so this [patient] left from being in a shelter to being placed in her own apartment [with her family]. Case manager 25

Transportation was another physical barrier for Community Connect's patients, with many patients reporting lack of access to a car and journeys on public transit taking up to five times longer than expected to get to appointments. Older patients, patients with accessibility needs, and patients with small children reported the most challenges, leading administrators to link with community organizations and rideshare companies (e.g., Lyft and Uber) to provide free transportation to patients' appointments.

3.5.3. Administrative and Technological Barriers to Social Service Access Posed Challenges for Most Patients and Case Managers Supporting Them

Administrative barriers to accessing Medicaid and social services, as well as complex eligibility requirements, posed challenges for most patients and case managers supporting them. This was especially true for patients who were unhoused and/or experiencing serious mental illness. Long wait times, complex application and reapplication processes, and highly specialized knowledge needed to enroll in public insurance or benefit options were reported as keeping patients from having equitable access to available resources. Case managers reported spending large portions of their work hours completing, submitting, and following up on social service applications on behalf of their patients. Medicaid churn was identified as an especially challenging issue for equity:

This whole group of people who are… the most marginalized and the most unstable are the people that are sort of cycling in and off of Medi‐Cal…If we end up serving only the people that manage to be stable enough that they maintain their benefit and a managed care plan, our concern is that we're going to miss addressing the group that we're trying to stabilize and get to that place. Administrator 12

Case managers and patients cited a shift away from paper applications and in‐person appointments to digital pathways for medical and social service access, especially during the COVID‐19 pandemic, as exacerbating inequity experienced by patients without access to internet and phone services. To address this, CommunityConnect began providing free, county‐sponsored cell phones.

[Cell phones] were not things that were originally in the [CommunityConnect] package…we figured out that in order to take good case management our patients needed to have a phone…and then how do we, you know, transition them into a way that they can sustain having a phone? Administrator 03

3.5.4. Federal Funding Was Viewed as Imperative for Program Implementation and Sustainability

Administrators viewed CMS approval of the Medicaid Section 1115 waiver that funded CommunityConnect as critical to the county's ability to innovate, expand, and deepen the infrastructure, staff, and services offered to integrate at‐risk patients' social and medical services. Administrators also attributed much of the engagement and sustainability of internal and external partnerships to the financial incentives they were able to provide through this funding.

I think, for a lot of the [program's] partners, this was a whole new, and I guess it is true, that was the whole point of the project, from the fed level and the state level, is that they were funding things that had never before been funded within the context of public health services. It was an opportunity for a lot of that to finally be able to address what we knew to be the core issues contributing to people's welfare. Administrator 12

4. Discussion

As more healthcare providers develop and implement social care interventions, there is a need to document lessons learned. Existing qualitative evidence suggests that efforts to integrate medical and social services are limited by poor access to and availability of resources and insufficient data integration across healthcare and social service organizations [36, 46]. Research has also highlighted the potential harms of social risk screening to patients and patient‐provider relationships if not implemented in a trauma‐informed, patient‐centered manner [47]. These studies support our assessment of factors influencing equitable implementation of CommunityConnect; however, factors affecting equitable implementation for frontline staff and patients remain under‐examined. The current study applied the HEIF to identify key factors influencing equitable implementation of CommunityConnect. Use of the HEIF supported a thorough assessment of factors affecting equitable implementation, with attention paid to key stakeholders across hierarchical levels and to historical influences on health and equity that can be less prominent in other implementation science frameworks.

Overall, we found that the use of multidisciplinary case management teams was a key feature of equitable implementation in CommunityConnect. Within case management teams, the inclusion of staff with multidisciplinary expertise and varied lived experiences supported shared learning and collaborative cross‐training while flattening hierarchical power imbalances between disciplines. However, CommunityConnect's design and implementation did not sufficiently account for the inequitable emotional demands of case management work on frontline case managers in the form of exposure to trauma and compassion fatigue. In the absence of resources focused on supporting employee resilience and wellness, the negative impacts of these exposures on case manager mental health are well documented in the literature [48, 49, 50, 51]. Considering the racial, gender, and socioeconomic intersectionality of individuals hired as frontline case managers—often women identifying as people of color and categorized as middle to lower income—is also imperative to prevent and address disproportionate decreases in well‐being through equitable implementation [52, 53]. Future implementation efforts incorporating these highly skilled and demanding roles should include structural, supervisory, and financial supports to address the disproportionate weight of case management work on frontline staff.

The current study also highlighted the importance of organizational assets in the form of intellectual, human, and social capital (e.g., experienced nursing leadership with express commitment to equity) for equitable implementation. Our findings corroborate evidence in the practice‐based and implementation science literature that strong leadership facilitates organizational readiness for change, especially when individuals in these roles champion intervention implementation through positive messaging and information sharing, and contribute expertise and experience leading previous change efforts [54, 55]. CommunityConnect's investment in developing a robust data infrastructure and analytic team prior to the program's implementation also supported a more equitable approach to the identification of eligible patients through the integration of social factors data in their predictive risk algorithm. This infrastructure also facilitated more equitable case management workflows as the universal data entry system minimized the need for double or triple entry of program data into multiple databases, an administrative challenge that has been documented in several other integrated case management initiatives [55, 56, 57, 58].

These findings corroborate those in another study that applied the HEIF to assess a social needs screening intervention within a single primary care setting, further highlighting the value of HEIF as a tool for assessing equity within social care interventions [59]. Our study expanded on this prior work by surfacing novel implementation factors related to power dynamics within and across organizations (e.g., equitable power sharing within teams) and privilege in the form of intellectual and social capital (e.g., technological literacy).

Finally, CommunityConnect was unique in that a short‐term influx of federal funds allowed the county to overcome a systemic lack of funding for integrated case management initiatives and more equitably distribute services to eligible Medicaid members. However, the time‐bounded nature of this funding presented an equity concern if the infrastructure, services, and staff enabled could not be sustained beyond the 5‐year funding period [60]. Poor sustainability of funding for prevention‐focused interventions is a well‐documented challenge, and evidence shows that insufficient attention to the sustainability of these programs can undermine financial and time investments, as well as associated impacts on health outcomes over time [61, 62, 63]. Assessing societal factors influencing equitable implementation, as described here, is only an interim step while we—researchers, practitioners, and citizens—also seek to change systems and structures perpetuating inequities. Systemic changes beyond the scope of case management initiatives are needed to combat the exacerbation of health inequities by administrative barriers to service access, racism and discrimination against historically marginalized communities, and insufficient supply of affordable housing and efficient public transportation [64, 65, 66, 67].

4.1. Limitations

Limitations include the retrospective nature of the analysis. Patients, case managers, and administrators were not consistently asked about equitable implementation in a structured or semi‐structured way. These results also reflect a single county's experience and may not be generalizable to other programs. Finally, we are not yet able to assess the impact of CommunityConnect's implementation on equity specific to patient healthcare access and outcomes, but a future mixed methods study combining the evaluation's quantitative outcomes around service distribution and access with the qualitative results might provide early signals.

4.2. Conclusion

Application of the HEIF supported the identification of multi‐level factors influencing equitable implementation. Future case management programs aiming to equitably align social and medical services should consider and actively plan for investment in multidisciplinary case management teams, with particular attention to case manager wellness through structural, interpersonal, and financial supports; organizational readiness for equitable implementation via committed, experienced leadership; and intervention upon systemic factors hindering equitable engagement of historically marginalized groups.

Conflicts of Interest

The authors declare no conflicts of interest.