For Super-Utilizers, Integrated Care Offers A New Path

Paper
Key Questions Answered
  • How do social, environmental, and behavioral factors affect health?
  • What are examples of successful integrated care models that provide behavioral health and social services such as food, housing, and transportation?
  • How can I expand a patient’s care from a single provider to an integrated health team?
Key Themes and Takeaways

This resource describes the mission of the National Center for Complex Health and Social Needs and examines several versions of integrated care models, including the Camden Coalition of Healthcare Providers in New Jersey, the Southcentral Foundation’s Nuka System based in Alaska, and CareOregon.

  • In December 2016, hundreds of health care professionals and consumers came together to share best practices around caring for the most vulnerable and chronically sick Americans and to launch the National Center for Complex Health and Social Needs.
  • Many versions of integrated care models are being tested, but successful models have commonly relied on building strong connections with local community organizations that understand the needs of their residents related to social determinants of health.
  • Two highly regarded programs are the Camden Coalition of Healthcare Providers in New Jersey and the Southcentral Foundation’s Nuka System in Alaska; both programs have produced data showing intensive outreach and long-term engagement in the local community can lead to better health outcomes. They inspired CareOregon, a nonprofit Medicaid health plan.
Authors
Bara Vaida
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
Level of Evidence
Expert Opinion
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