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Resource referral guide & template
This guide from Health Leads was developed from a workshop presentation at Putting Care at the Center 2018. The guide was created to help healthcare and community-based organizations create and maintain high-quality resource listings to address clients’ social needs, and includes the steps these organizations can take to better understand and proactively address barriers to […]...Read more
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Case study: Generalizability framework
This tool from the Abdul Latif Jameel Poverty Action Lab (J-PAL) North America was developed from a workshop presentation at Putting Care at the Center 2018. The resource introduces J-PAL’s “generalizability framework,” a practical approach for using evidence to assess whether a given program can be replicated or adapted to work in a new setting. […]...Read more
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Reducing health disparities: Strategies to support effective community health workers
This policy brief from the Penn Center for Community Health Workers, home of the IMPaCT community health worker (CHW) model, was developed from a workshop presentation at Putting Care at the Center 2018. The brief highlights financing and policy strategies – including value-based payments, program accreditation, and incentives to implement solutions correlated with high-quality programs […]...Read more
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Continuum case conferencing for an improved behavioral health system
This brief from Alameda County Care Connect and Bright Research Group details lessons and best practices learned from a pilot complex care intervention for high utilizers of psychiatric emergency services in Alameda County. The pilot convened monthly case conferences with a diverse group of providers from the psychiatric emergency system, County Health Care Service Agency, […]...Read more
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Helping our children grow and thrive: Leveraging the health care system to prevent and mitigate adverse childhood experiences and advance equity in childhood
This report from Families USA’s Center on Health Equity Action for System Transformation lays out policies and strategies to leverage the healthcare system to address adverse childhood experiences (ACEs). It includes recommendations for federal and state policymakers, state Medicaid agencies, health system leaders, and individual providers, arguing that new efforts to broaden the definition of […]...Read more
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Promising health and housing collaborations
This report from the National Housing Conference profiles health and housing initiatives in Oregon, Tennessee, and Massachusetts that exemplify practical and actionable ways that housing developers can work together with health systems and managed care organizations to build new affordable housing units while reducing unreimbursed medical costs in high-cost populations. The report includes insights from […]...Read more
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Accessing housing (July-August 2019)
Safe, stable housing is a key component of maintaining health and wellbeing. However, the identification documents required to qualify for public or affordable housing can be difficult to obtain for people with complex health and social needs. Individuals experiencing homelessness may lack the stability and resources needed to obtain the necessary documents for housing. ...Read more
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Home-based primary care resources
This toolkit from the American Academy of Home Care Medicine includes tools to help implement home-based primary care for high-risk, homebound patients in order to shift the use of healthcare services from emergency and inpatient care to community-based general care, and to improve patients’ quality of life. The toolkit includes a white paper, FAQ, video […]...Read more
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It’s about trust: Low-income parents’ perspectives on how pediatricians can screen for social determinants of health
This report from Public Agenda and United Hospital Fund provides the results of qualitative research aiming to better understand parents’ perspectives on social determinants of health, receptiveness to discussing social needs with pediatricians, and ideas for making social determinants of health screenings work well. Through focus groups with low-income parents in New York City, the […]...Read more
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Blueprint for health plans: Integration of CBOs to provide social services and supports
This report from The SCAN Foundation highlights successful partnerships between health plan networks and community-based organizations (CBOs) to help meet the needs of older adults with complex health and social needs. Focused on California, the report provides a framework for implementing sustainable health plan and CBO partnerships. Read the report...Read more
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Opportunities to advance complex care in rural and frontier areas
This brief from the Center for Health Care Strategies (CHCS) explores obstacles faced by rural and frontier health care organizations in providing complex care, including: workforce shortages, unique “rural” social determinants of health, and the self-sufficient character of many community members. It includes examples of rural communities that are enhancing complex care delivery through workforce […]...Read more
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HUD policy brief on rural homelessness: Understanding the impact and potential for health centers
This policy brief from CSH provides an overview of rural homelessness as well as ways that health centers can address rural homelessness in their communities. These strategies include partnering with local providers, screening for homelessness and housing instability, and participating in coordinated entry. Read the brief...Read more
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Multi-sector partnerships (May-June 2019)
To address individuals’ array of needs, the field of complex care must work across sectors at both the individual and systemic levels to break down silos. Effective multi-sector partnerships are essential to building a lasting ecosystem that provides whole-person care for vulnerable populations and helps to address the social determinants of health....Read more
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Supportive housing needs in the United States
This toolkit from CSH includes data visualizations, evidence, and research on supportive housing needs in the US. It includes a review of supportive housing research broken into outcomes and data reports of supportive housing need broken out by population. Explore the toolkit...Read more
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IMPACT! How consumers have shaped health system delivery reform
This report from Community Catalyst’s Center for Consumer Engagement in Healthcare Innovation highlights examples of how consumers with complex health and social needs, organized and supported by the Center’s state and local advocacy partners, have shaped policy and practice in delivery reform initiatives. It also provides a framework for understanding consumer impact, including process impacts, […]...Read more
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Partnerships, programs, and platforms: Addressing social determinants of health through multi-sector data sharing
This report from the National Interoperability Collaborative, a joint project of Stewards of Change Institute and AcademyHealth, provides an overview of the technology behind emerging multi-sector initiatives is geared toward those who are beginning social determinants work, preparing to scale up existing programs, or looking for new partners. It highlights some of the leading initiatives […]...Read more
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Achieving health equity and wellness for Medicaid populations: A case study of community based organization (CBO) engagement in the Delivery System Reform Incentive Payment (DSRIP) program
This issue brief from AcademyHealth, Health Management Associates, and the Disability Policy Consortium showcases the role that community-based organizations (CBOs) can play in advancing health equity and wellness for individuals and communities in delivery system reform. It highlights current and potential barriers to positive collaboration between CBOs and healthcare organizations from the vantage point of […]...Read more
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Trauma-informed care (March-April 2019)
The significance of trauma has become an increasingly accepted tenet of complex care. While there is general agreement on the core principles of trauma-informed care and that trauma can negatively impact an individual’s health and wellbeing, our March 2019 webinar and April 2019 Office Hours for Complex Care focused on how to apply trauma-informed approaches […]...Read more
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Community resource referral platforms: A guide for health care organizations
This report from Social Interventions Research & Evaluation Network (SIREN) details the functionalities of nine different software platforms that enable healthcare organizations to more easily identify and refer patients to social service organizations. It includes a side-by-side comparison table and detailed profiles of the platforms’ features, as well as implementation lessons learned and recommendations from […]...Read more
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DASH-NPHL legal resource bibliography
This legal bibliography from Data Across Sectors for Health (DASH) and the Network for Public Health Law (NPHL) provides over 100 resources including papers, toolkits, and other materials focused on privacy, consent, and policy documentation to guide community data practitioners and their legal advisors to overcome legal challenges to data sharing. The resources are organized […]...Read more
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High-need, high-cost patient personas
This toolkit from The Commonwealth Fund and Healthwise includes a series of “personas” for different types of individuals with complex health and social needs, as well as their caregivers. The personas help depict the experiences, motivations, and goals of a group of patients, as well as the barriers they face. Personas included in this toolkit […]...Read more
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The complex care hospitalist program at Boston Medical Center
This series of videos from the Better Care Playbook provides an introduction to the complex care hospitalist model that is a collaboration between Commonwealth Care Alliance, Boston Medical Center, and providers in the community. Questions answered include “how do you define a complex care patient?”, “what is a complex care hospitalist?”, “what are the key […]...Read more
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Strengthening Medicaid long-term services and supports in an evolving policy environment: A toolkit for states
This toolkit from the Center for Health Care Strategies (CHCS) and Manatt Health provides a menu of long-term services and supports (LTSS) reform strategies adopted by state innovators. It identifies concrete policy strategies, operational steps, and federal and state authorities that states have used to advance LTSS reforms, along with case studies and advice for […]...Read more
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Quick reference guide to promising care models for patients with complex needs
This guide from The Commonwealth Fund summarizes the target populations, key features, and evidence of impact for 28 promising care models for adults with complex needs. It also includes a point of contact for each model. View the guide...Read more
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How do community health centers pay for social care programs?
Community health centers have long incorporated social correlates of health into their work, and this report from the Social Interventions Research & Evaluation Network (SIREN) and the Center for Care Innovations lays out ways in which community health center innovators initiate and sustain social care programs, as well as the many barriers they face in […]...Read more
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A conversation about social movements with Ai-jen Poo
Putting Care at the Center 2018 conference keynote Ai-jen Poo sat down with Jackie Judd to talk about building social movements around care from the bottom up. Ai-jen Poo is the co-director of Caring Across Generations and executive director of the National Domestic Workers Alliance. Jackie Judd, plenary moderator for the 2018 conference, has reported […]...Read more
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Systematic review of social risk screening tools
This meta-tool from Kaiser Permanente and the Social Interventions Research and Evaluation Network (SIREN) compiles and reviews social risk screening tools to allow researchers, health care system administrators, providers, and community partners to select social risk assessment tools most appropriate to their setting and population. Toolkit users can search for tools that screen for risk […]...Read more
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Medicaid benefits database
This database from the Kaiser Family Foundation and Health Management Associates provides a comprehensive look at the Medicaid benefits provided by each state across the country, including coverage for things like transportation, long term services and supports, and home and community-based care. Useful for policymakers and advocates looking to compare benefit offerings across states or […]...Read more
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Fact sheet: Complex care health settings and medical-legal partnerships
This fact sheet from the National Center for Medical Legal Partnership, MLPB, the National Center for Complex Health and Social Needs, and PennMedicine Lancaster General Health captures learnings from a medical-legal partnership pre-conference held at our annual conference, Putting Care at the Center, in December 2018. It describes five complex care settings, including the Camden Coalition […]...Read more
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Re-envisioning care for people with involved disabilities
This video series from Community Catalyst’s Center for Consumer Engagement in Health Innovation (CCEHI) examines how to design person-centered care for people with involved disabilities. It aims to support clinicians and health system leaders in understanding and adopting principles of person-centered care through four short educational videos featuring Dr. Robert Master and other clinician and […]...Read more
Events & Webinars
Promising complex care models in rural and frontier communities
Date: September 17, 2019
Time: 1:00-2:00 pm ET
Webinar
Putting Care at the Center 2019
Start date: November 13, 2019
End date: November 15, 2019
Conference
Recent News
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New implementation science and practice resources
Announcing three new resources — from Health Leads, J-PAL North America, and the Penn Center for Com...
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Complex care field-building update and new fall projects
It’s been eight months since we released the Blueprint for Complex Care, a national strategic plan f...
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Practical skills, tech, and teams: My Putting Care at the Center experience
By Lisa Rotenstein MD MBA, Founder of CareZooming As a resident physician in internal medicine who h...
The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition.