Aligning the Delivery and Finance Systems of the Social Service Sector to Absorb Hospital/Clinical Referrals

Across the country, efforts are underway to determine how to design and implement systems to bridge health and public health services to community resources (most often nonprofit and public sector agencies outside of the health system). At the heart of this effort is the common determination that these systems will refer patients to “community resources” without little explanation or seemingly clear definition of what “community resources” really means, nor how to align the delivery and financing of this part of the system to overall ROI and health systems savings. As the focus on building a social determinants of health screening and referral system across sectors is gaining increased attention and investments, particularly from hospital systems, it is increasingly clear that this part of the system is the most vulnerable and uncertain. Yet to date a focus on the carrying capacity of the social services sector to receive these referrals has largely been earmarked as “something to figure out later”. It is our concern that if hospital/clinical systems are successful at building strong SDOH screening and referral systems, that the social services sector will lack the capacity to absorb these new “clients” and that this very factor will in turn, break the entire system. In this proposal, we address this issue in an empirically rigorous way, to 1) utilize the existing PARTNER (Program to Analyze, Record, and Track Networks to Enhance Relationships – www.partenrtool.net) dataset to understand and define what is meant by “community resources” in a SDOH framework, 2) map the system factors (inputs, outputs, and interactions) that shift the capacity of community to successfully absorb increased referrals and determine where the financing and delivery of these factors is aligned, or not, 3) utilize two case studies to collect data on these inputs and outputs to test their thresholds for success and failure, and 4) develop some evidence-based practices to build the capacity of the sector and prepare it in a way that will ensure this part of the larger system is strong and sustainable and will be ready when hospitals, clinics, and private practice are successful at integrating SDOH screening into their culture and work flow. Scope