Table 2.

Overview of Cross-Sector Care Coordination Programs in Included Publications

Program	Geographic location	Approximate number of patients or sites	Type of lead organization	Eligible population	Main social services addressed	Primary mode of patient communication	Primary care coordination staff type
Camden Coalition of Healthcare Providers37	Camden, New Jersey	3 hospitals, 2 FQHCs, and numerous other medical practices and social service agencies	Multidisciplinary coalition	Patients with a high number of hospital admissions	Housing, Benefits assistance	On-site, In the field	Physician or mid-level provider, Social worker
Community Health Access Project38	Richland County, Ohio	115 patients in the intervention group and 115 controls	Community-based organization	Women at risk of unfavorable birth outcomes	Housing, Education or employment assistance, Benefits assistance, Transportation	In the field	Community health worker or peer coach
Emergency Department Care Coordination Intervention39	Boston, Massachusetts	36 patients in the intervention group and 36 controls	Emergency department	Patients with high emergency department utilization	Benefits assistance, Transportation	On-site, In the field, Telephonic	Community health worker or peer coach
Health Leads Help Desks40–42	Communities across the United States	More than 100,000 patients at more than 2500 health care institutions from 1996 to 2017	Health system, Primary care practitioner office or clinic	Patients with unmet basic resource needs	Housing, Education or employment assistance, Benefits assistance, Transportation	On-site, Telephonic	Nonpermanent volunteers
Hennepin Health43–46	Hennepin County, Minnesota	10,000 patients in 1 Medicaid ACO	Accountable care organization (ACO)	Low-income adults who gained coverage through Medicaid expansion	Housing, Education or employment assistance, Benefits assistance	On-site, In the field, Telephonic	Community health worker or peer coach, Physician or mid-level provider
Johns Hopkins Community Health Partnership47	Baltimore, Maryland	3000 community-based patients and 40,000 acute care patients	Health system	Adults on Medicaid and Medicare at high risk of hospitalization	Housing, Education or employment assistance, Transportation	On-site, In the field, Telephonic	Community health worker or peer coach, Physician or mid-level provider, Social worker
Maryland Medicaid Health Homes48,49	Communities in the State of Maryland	48 health home sites	Behavioral health organization	Adult Medicaid participants with serious mental illness	Housing, Education or employment assistance, Benefits assistance, Transportation	On-site	Physician or mid-level provider
Medicaid Opioid Health Homes50	Three states (Maryland, Rhode Island, and Vermont)	10,000 patients over 3 states	Behavioral health organization	Medicaid participants with opioid use disorder	Housing, Education or employment assistance, Benefits assistance, Legal assistance, Transportation	On-site	Physician or mid-level provider
Medical Student Advocate Program51	Philadelphia, Pennsylvania	369 patients in the first 2 years	Primary care practitioner office or clinic	High-risk patients with socioeco-nomic needs	Housing, Education or employment assistance, Benefits assistance, Transportation	On-site, Telephonic	Nonpermanent volunteers
New York Health Homes52	New York State	More than 100,000 individuals over 31 health home sites	Varies	Adults on Medicaid with multiple chronic health conditions, or with HIV/AIDS or serious mental illness	Housing, Benefits assistance, Other social services (not defined)	Not specified	Not specified
Pathways to a Healthy Bernalillo County53	Bernalillo County, New Mexico	13 collaborating organizations	Health system	At-risk, socially disconnected adults	Housing, Education or employment assistance, Benefits assistance, Legal assistance, Transportation	In the field	Community health worker or peer coach
Project Connect54	New York, New York	75 patients at 1 urban psychiatric emergency room	Emergency department	Patients with high emergency department utilization	Housing, Education or employment assistance, Benefits assistance	On-site, In the field	Community health worker or peer coach
Telephone Care Management Intervention55	Five Denver-area counties in Colorado	3540 patients in the intervention group and 1524 controls	Managed care organization	Adults on Medicaid who were blind or disabled	Housing, Transportation	Telephonic	Physician or mid-level provider, Care managers from diverse professions
Together4Health56	Cook County, Illinois	5000 patients in initial 3 years	Primary care practitioner office or clinic	Adults on Medicaid with multiple health conditions and chronic illnesses	Housing, Other social services (not defined)	On-site, In the field	Community health worker or peer coach, Physician or mid-level provider, Social worker
Transitions Clinic57	San Francisco, California	185 patients in initial 22 months	Primary care practitioner office or clinic	Adults recently released from jail or prison with chronic medical conditions	Housing, Education or employment assistance, Legal assistance	On-site, In the field, Telephonic	Community health worker or peer coach, Physician or mid-level provider
Truman Medical Centers High-Utilization Team Model58	Kansas City, Missouri	198 patients enrolled	Health system	Adult patients with high utilization	Housing, Benefits Assistance, Other social services (not defined)	On-site, In the field, Telephonic	Community health worker or peer coach, Physician or mid-level provider, Social worker
VA Homeless-Oriented Primary Care Clinic59	Providence, Rhode Island	177 patients enrolled	Health system, Primary care practitioner office or clinic	Homeless adult veterans	Housing, Education or employment assistance, Benefits assistance	On-site	Physician or mid-level provider
VA Homeless Patient Aligned Care Team60	Communities across the United States	18,000 patients at 58 medical facilities in 2015	Health system, Primary care practitioner office or clinic	Homeless adult veterans	Housing, Education or employment assistance, Benefits assistance, Legal assistance, Transportation	On-site, In the field	Physician or mid-level provider, Social worker
Vermont Blueprint for Health61	Communities in the State of Vermont	60,000 patients over 3 pilot sites	Primary care practitioner office or clinic	All citizens in the state	Benefits assistance, Transportation	On site	Physician or mid-level provider

Results include only the program details that were reported in included publications, and may omit details that were not reported.

FQHC, Federally Qualified Health Center; VA, Department of Veterans Affairs.