Abundant evidence confirms the powerful influences that social and economic factors exert on health status across the life-span.1 The programs and services designed to address these factors, such as housing and income assistance, are disconnected from mainstream health services. As a result, formal health systems frequently fail to improve patient outcomes because clinical services alone cannot fully address the social, environmental, and economic factors underlying poor health.2 The fragmentation between formal health systems and social services has been further exacerbated by federal funding cuts for Medicaid, public health programs, and social service programs.
The Robert Wood Johnson Foundation created the Systems for Action (S4A) research program in 2015 to better understand these issues. Studies supported by S4A evaluate mechanisms to align health systems’ resources and operations on shared priorities to improve population health and advance health equity.
RESEARCH PRIORITIES AND PRINCIPLES FOR SYSTEMS ALIGNMENT
S4A prioritizes studying five mechanisms for promoting systems alignment: governance, financing, workforce, data systems, and policy (Figure 1).3 Two principles guide S4A research priorities: aligning medical care, public health, and social services to advance equity, and strengthening the engagement of communities most affected by health disparities.
FIGURE 1—
Mechanisms for Promoting Alignment Across Systems for Medical Care, Social Services, and Public Health
Note. CDC = Centers for Disease Control and Prevention.
S4A has learned from both successes and failures in systems alignment, including studies that
supported partnerships between clinical and community organizations to implement evidence-based public health programs,4–7
helped health care providers integrate social needs screening data into routine patient care,8
incorporated financial empowerment training and peer support services that assist low-income families,9
enabled community organizations to access Medicaid funding to expand social support services,10 and
created flexible Medicare payment models that support teams of physicians and community health workers to deliver social services for patients with complex medical and social needs.11
S4A studies also reveal failures in systems alignment, such as when decision-making authority remains unequal among collaborating organizations. Such imbalances can result in power asymmetries that crowd out the perspectives of community organizations. To address this problem, S4A created the System Alignment Innovation Hub in 2023 to support community organizations in developing and testing their own ideas for aligning systems in ways that better serve their communities. The Innovation Hub provides organizations with free technical assistance, training, peer support, and access to pilot funding that can be used to develop and test community-based approaches for systems alignment.12 Over the past three years, the Innovation Hub has provided technical assistance, training, peer support, and pilot funding to more than 100 organizations.
This AJPH special supplement features new evidence and lessons learned from S4A during the most recent three-year period.
COMMUNITY-LED APPROACHES
Gawande et al. (p. xxx) describe findings from a community-led pilot study demonstrating how a peer-led intervention can achieve successful integration into busy primary care clinical settings. A pair of research articles by Fort et al. (p. xxx) and Walker et al. (p. xxx) use network analysis and system science methodologies to investigate complex patterns in community-based service delivery networks, identifying valuable areas of alignment and synergy that reduce barriers to coordination.
GEOGRAPHIC VARIATION AND LONGITUDINAL CHANGE
Three research articles evaluate multisector partnerships focused on geographic variation and longitudinal change. Brewster et al. (p. xxx) analyze the effectiveness of a national program that uses community-led partnerships to promote vaccination coverage among racial and ethnic minority populations. Williams et al. (p. xxx) analyze longitudinal data from a national cohort of nurse home-visiting programs, finding evidence of improved outcomes with better alignment with local service providers. Mitchell et al. (p. xxx) analyze long-run changes in public health partnerships, finding benefits from decentralized governance in selected community settings.
GOVERNANCE, FINANCING, AND POLICY MECHANISMS
A set of research articles examines specific governance, financing, and policy mechanisms for promoting systems alignment. Bunger et al. (p. xxx) evaluate the ability of regional governing boards to promote systems alignment for families and children affected by substance use disorder. Thakor et al. (p. xxx) use a simulation model to estimate the effects of a bond financing instrument to encourage competing Medicaid managed care organizations to invest in social drivers of health. Chandrasekaran (p. xxx) examines disparities in the use of telehealth services across geographic areas and racial and ethnic minority groups. An essay by Hijano (p. xxx) considers how behavioral economics can be applied to improve equity in childhood immunization delivery.
Collectively, the studies presented in this special supplement demonstrate that systems change aligned toward equity is possible. This body of evidence is especially timely amid federal funding cuts and policy shifts affecting medical care, health care programs, and social programs. This new evidence and more future research can elucidate how best to adapt and scale successful systems alignment to different community contexts and improve population health equity over time. S4A has made a significant impact, and we encourage the broader field of health equity researchers to build on and extend this systems change approach.
5 Years Ago
Public Health Systems and Social Services: Breadth and Depth of Cross-Sector Collaboration
We surveyed local public health of?cials in a strati?ed random sample of 776 com-munities regarding the implementation of 19 public health activities and the types oforganizations engaged in these activities. . . In 2018, the extensive margins for social service involvement ranged from 25.3% of communities engaging parks, recreation, and physical activity organizations to 73.8% of communities engaging organizations that provide assistance with housing, shelter, or utilities. . . Notably low was collaboration with justice-related organizations such as legal assistance and law enforcement. The extensive margins observed demonstrate cross-sector relationships spanning the public health, housing, and food sectors are now widespread across the United States, giving most communities viable avenues for addressing selected social determinants of health. However, public health relationships with many other social services are considerably less prevalent, highlighting opportunities for public health agencies to expand their reach …
From AJPH, Supplement 2, 2020, pp. S232–S233.
13 Years Ago
Networks to Strengthen Health Systems for Chronic Disease Prevention
Networks for preventing chronic diseases and delivering more integrated services to chronic care patients are becoming important features of health systems. Not all networks will succeed in achieving their goals or ultimately improving the health of populations… A systematic research agenda is needed to examine these issues and may be initially structured around the development of prevention-speci?c measurement strategies that facilitate improved assessment of network performance and collaboratively developed feedback mechanisms that make better use of data to drive change in network activities. These priority research areas must form part of a program of research that seeks to integrate the expertise of clinicians, public health professionals, stakeholder engagement specialists, economists, health services and systems researchers, health policy specialists, and social scientists. The program must bridge these disciplines, build on research and practice expertise, and mobilize knowledge in ways that improve practice.
From AJPH, November 2013, p. e46
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
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