National Center
For Complex Health and Social Needs
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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
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7-Day Pledge: Avoiding hospital readmissions through rapid connection to primary care
This evaluation of the Camden Coalition of Healthcare Providers’ 7-Day Pledge program, published in JAMA Network Open, shows that rapid connection to primary care after hospital discharge can help avoid readmission. Patients who had primary care appointments within seven days of hospital discharge had significantly lower numbers of 30- and 90-day hospital readmissions. Below, find […]...Read more
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Blueprint for Complex Care (January-February 2019)
Healthcare innovators across the country are pioneering new approaches to provide better care at lower cost for people with complex health and social needs. Advancing the field of complex care and dramatically improving care delivery for the nation’s most vulnerable patients, however, cannot be achieved by one organization alone. The recently released Blueprint for Complex […]...Read more
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Essential needs roadmap
This toolkit from Health Leads provides guidance, milestones, and supporting resources for healthcare organizations looking to incorporate social needs into their practice. The toolkit is broken down into ID & screening, navigation & resource connection, social health team & workflow, community partnerships, data & evauation, and leadership & change management sections. The entire roadmap is […]...Read more
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How ACOs are caring for people with complex needs
This report, authored by researchers from the Dartmouth Institute for Health Policy and Clinical Practice and supported by The Commonwealth Fund, The John A Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, the Robert Wood Johnson Foundation, and The SCAN Foundation, provides an overview of strategies employed by accountable care organizations (ACOs) across the […]...Read more
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Expecting better: Improving health and rights for pregnant women who use drugs
This publication from the Open Society Foundations provides a framework for advocates and providers who work with pregnant people who use drugs, to ensure that their rights are respected and that they are connected to the services they need. The document includes sections on combatting misinformation and stigma surrounding drug use and pregnancy, connecting patients […]...Read more
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New faces of the complex care workforce: Reflecting and connecting with patients
A collection of profiles of “non-traditional health workers” from the Center for Health Care Strategies. The individuals profiled share experiences with the patients they serve and can provide a more personal approach to engagement and care coordination. They have titles like community health worker, care navigator, community paramedic, and peer specialist, and use their knowledge […]...Read more
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2018 Closing Remarks: Susan Cooper
Closing remarks from Susan Cooper, Senior Vice President/Chief Integration Officer of Regional One Health....Read more
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2018: The Next Generation of Movement Builders
The Next Generation of Movement Builders was the final plenary session of December 2018’s Putting Care at the Center conference, the second annual conference of the National Center for Complex Health and Social Needs. In recent times, youth from across the Nation have banded together to demand a change to the status quo. Building a […]...Read more
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2018 Keynote: Ai-jen Poo
The keynote address of Putting Care at the Center 2018, the third annual conference of the National Center for Complex Health and Social Needs. Putting Care at the Center 2018 was December 5-7, 2018, in Chicago, IL. Ai-jen Poo, Director of the National Domestic Workers Alliance and the Co-Director of Caring Across Generations, presented on […]...Read more
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2018: The Power of Partnership in Transformation
The Power of Partnership in Transformation was the second plenary session of December 2018’s Putting Care at the Center conference, the third annual conference of the National Center for Complex Health and Social Needs. Health care consumers want care that is coordinated, convenient, cost-effective, well-communicated, and respects what matters to them. Consumers can—and should—play a […]...Read more
Events & Webinars
Accessing housing: Overcoming the documentation barrier
Date: July 29, 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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Bringing it home: The shift in where healthcare is delivered
As complex care gains momentum, organizations and providers are finding innovative ways to serve ind...
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What the regional convening selection process taught us about the field of complex care
Why regional convenings? In our work across the country, system administrators and providers alike h...
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CAPABLE: Addressing the home environment through team-based care
When the Johns Hopkins CAPABLE team met “Edna,” she hadn’t been downstairs in her own home for two y...
The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition.