This tool can support health care and community-based organizations in building sustainable cross-sector partnerships.

A program to connect Medicaid ACO enrollees with nutrition and housing-related services demonstrated early indications of effectiveness.

Insights from patient-level encounter histories can support optimizing care coordination team staffing for high-need patients.

An overview of NYC Health + Hospital’s implementation of a primary care-based social needs screening and referral program, including key implementation challenges and success factors.

Embedded peer navigators provide support and mentorship for people experiencing homelessness, leading to increases in chronic disease screening and referrals.

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

A novel street psychiatry program offers essential mental health support to unsheltered individuals experiencing homelessness.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.

Guide for hospitals to address housing instability by understanding the evidence, evaluating different approaches, and exploring case studies of health system-led programs.

A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.

A regional approach to health care transformation.