Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health

September 2019

How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address this critical question and identify practical strategies for integrating social services into clinical care delivery. The committee identified existing and emerging activities to integrate social care, components for successful integration, and recommendations for more effective integration with the goals of improving health and reducing health disparities.

Five key activities to support the integration of social care into health care include: (1) identification of patient social risk factors; (2) adjustment of clinical care to accommodate social barriers; (3) assistance to connect patients with needed social resources; (4) alignment of health system and community-based resources; and (5) advocacy to promote policies that will address social needs. For successful adoption of these activities, the NASEM committee identified three key elements: an appropriately staffed and trained workforce, including social workers and/or community health workers; health information technology to support data sharing across health systems and social service sites; and alternative financing models, like accountable care organizations, to provide the funding flexibility needed to support integration.

The NASEM committee outlined five goals supported by actionable recommendations for health care stakeholders to improve integration of social care into health care. These include: 

  1. Design health care delivery to integrate social care into health care using the five activities;
  2. Build a workforce to integrate social care into health care delivery;
  3. Develop a digital infrastructure that is interoperable between health care and social care organizations;
  4. Finance the integration of health care and social care; and
  5. Fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care practices in health care settings.
Posted to The Playbook on
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How can services that address social needs be integrated into clinical care?
  • What infrastructure is necessary to effectively integrate social services into clinical care pathways?
Level of Evidence
Expert Opinion
What does this mean?