We are pleased to present this supplement of AJPH. At its core the intent of cross-sector alignment is to find practical ways to combine medical care, public health, and social services. Although many will agree with this approach, in practice it has been difficult to implement systematically. This supplement aims to bridge that gap. The articles in the supplement fall into four categories: system design, funding, fostering multisectoral linkage, and practical examples.
SYSTEM DESIGN
A good introduction to the general approach is provided by Landers et al. (p. S178), working in conjunction with the Robert Wood Johnson Foundation’s Aligning Systems for Health program. Using an example developed in the state of Georgia and tailored to the coronavirus pandemic, the authors elaborate a health systems theory of change. They identify four core areas through which to organize efforts:
refining a shared purpose,
providing shared data with all partners,
ensuring long-term financing, and
building a governance structure emphasizing representation.
Bultema et al. (p. S235) describe another organizational rubric using the accountable communities of health model. This model is constructed around improving the holistic experience of health from the perspective of the individual. Firmly rooted in social determinants of health, the four parts of the goal are to improve sickness care, improve overall health, reduce costs, and improve the health care provider experience. The accountable communities of health model is relatively new, and its successful implementation in Eastern Washington shows how organizations became less siloed through this intentional approach. (Meyer et al. (p. S219) also used the accountable communities of health model in their implementation evaluation.)
The Washington example suggests that rural areas have unique public health workforce challenges. Owsley et al. (p. S204) point out public health activities shows rural areas lagging behind urban areas. In addition to having less comprehensive programming, rural areas also lost delivery capacity from 2014 to 2018. These findings reinforce the need for special attention to respond to rural needs.
ROLE OF FUNDING
For translating theory into practice, securing funding for cross-sectorial alignment is a fundamental impediment. Envision the difficulty in establishing an annual budget when juggling government-funded social work case management and fee-for-service private insurance for medical care—and that is not considering the even rarer funding for systems-level coordination. McCullough et al. present two perspectives on financing. They point out that the financing even within government is complex, with silos between local, state, tribal, and federal governments (p. S197). In another article (p. S181), McCullough et al. update the health impact pyramid to illustrate the tremendous misalignment between clinical care and social determinants of health.
To better understand public funding for public health, Leider et al. (p. S194) uncovered systematic bias in how expenditures are reported by government agencies. They found that a half to a third of official estimates of population-based public health spending include individual health services. This means that actual funding for population-level systems for health are even less funded than it seems. Of course, this will not come as a surprise to those working on the ground.
Directly related to funding is the development of the public health workforce. Ross and de Saxe Zerden (p. S186) turn a critical eye to building a workforce for health. And Islam et al. (p. S191) integrate multiple lines of research to provide practical examples of sustaining the health workforce. From New Mexico to New York, they compiled programs that have addressed sustainable personnel development.
MULTISECTORAL EFFORTS
A rich set of editorials and research reports dig deeper into the practicalities of multisectoral collaboration. To start with, Hamer and Mays et al. (p. S232) quantified public health engagement between housing, food assistance, economic development, environmental protection, and law and justice organizations. Their nationwide study reveals that cross-sectional relationships are fairly shallow, but housing and food security sectors are a bright point for integrated service delivery. Laurent et al. (p. S222) take another data-based approach connecting Medicaid and Seattle Housing Authority information to arrive at a shared understanding of health care utilization and opportunities for promotion. Using these data they identified new avenues for intervention, for example by observing that asthma diagnoses were two to three times higher for people in supportive housing than for the Medicaid population.
IMPLEMENTATION IN PRACTICE
Continuing along the theme of improving medical care delivery, some of the most robust studies came from evaluations of integrating social determinants of health in large urban hospital and health care settings.
Fiori et al. (p. S242) take an innovative approach by using primary care no-show visits to identify target populations with unmet social needs. In addition to accruing medical costs and inefficiencies, no-show visits serve as a proxy for unmet health needs. They report that a staggering number of nonshow visits are primarily owing to inadequate attention to social determinants of health.
Meyer et al. (p. S219) present the first results of implementing universal social determinants of health screening at four primary care practices in a Latinx neighborhood of New York City. With an emphasis on patient health literacy and an enabling information technology solution, the experience serves as a promising model for implementation elsewhere. Their experience pairs well with efforts at three primary care provider offices that are a part of the public New York City Health + Hospitals. They independently implemented screening for social determinants of health and created a linked workflow to make referrals.
Finally, three compelling articles articulate how integrated systems of care are needed to improve specific disease states and health needs. These cover preventative mental health (Nelson, p. S225), pediatric weight management (Atkins et al., p. S251), and postpartum visits (Howell et al., p. S215).
WHAT IS NEXT
The breadth of response encompassed by these articles is impressive. Although it is heartening to see such innovation, we also notice gaps for future research. First, the inherently linked nature of this field makes it difficult to disentangle intervention effects using a reductionist approach, and alternative methods would be welcome. Second, many implementation projects have evaluation as a goal secondary to service provision. As such, the data needed for rigorous impact assessment may be limited, such as data from control groups. It may behoove program designers to think more critically of evaluation and publication standards during inception.
Finally, readers may note an absence of articles enumerating biological health benefits resulting from paying attention to social determinants of health. Despite the inherent complexities, the next phase of health system integration would ideally focus on situational, behavioral, and biological outcomes. In the interim, reductions in financial cost may be put forward as a proxy for success. Although the cost-saving imperative is practical and a potential hook for sustainability, we should not lose sight of the humanity and lived experience of participants.
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.