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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Care Coordination.

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Strategy. Social Service Integration

Approach. Integrate social service into clinics to better coordinate the needs of children and families.

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Overview. Social service integration efforts coordinate access to services across multiple delivery systems and disciplinary boundaries such as housing, nutrition, disability, physical health, mental health, child welfare, transportation, and workforce services. Approaches to integrating and coordinating social services vary depending on community needs and service availability, and can be system- or sector-based, agency-based, or client- or family-based.[1] Multi-sector integration can be defined along a continuum, from smaller-scale service coordination to complete integration of multiple organizations and delivery systems.[2] Efforts can focus on improving collaboration across sectors, client pathways to service, or coordination and resource sharing across different levels of government.[3] Frequent features of collaborative social service integration include having common goals and a shared understanding of roles and responsibilities among organizational partners; sharing information about patients, care, and administration; and staff and professional interactions at all levels of organizations.[4]

Evidence. Moderate Evidence. Strategies based on moderate evidence show a clear trend toward positive results. While these approaches are likely to be effective, further research is needed to confirm their impact. Implement with evaluation to better understand specific local effects.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Social worker/resource navigator caseload and activity logs
  • Patient/family satisfaction surveys
  • Clinic-wide process and staffing metrics

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Community Health Factors.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Collaboration (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of healthcare providers and staff trained on screening for non-medical influences on health and connecting patients to relevant social services. (Indicates capacity building for integrated care)
  • Number of social service navigators or coordinators co-located or embedded within clinics to facilitate service integration. (Shows implementation of key integration strategies)

Quadrant 2:
Measuring Quality of Effort (“How well did we do it?”)

  • Percent of healthcare providers and staff trained on screening for non-medical influences on health and connecting patients to relevant social services. (Indicates capacity building for integrated care)
  • Percent of social service navigators or coordinators co-located or embedded within clinics to facilitate service integration. (Shows implementation of key integration strategies)

Quadrant 3:
Measuring Quantity of Effect (“Is anyone better off?”)

  • Number of clinic staff who report improved knowledge, skills, and confidence in addressing multiple causes of poor health outcomes and coordinating with social services. (Indicates the impact of training and capacity building efforts)
  • Number of referrals to social services that are completed and result in service initiation for children and families. (Shows the efficiency and effectiveness of referral process)
  • Number of children and families who experience improved health outcomes as a result of clinic-based social service integration. (Shows the impact of the integrated model)
  • Number of children and families who access and utilize needed social services as a result of clinic-based integration efforts. (Shows the effectiveness of service linkages and coordination)

Quadrant 4:
Measuring Quality of Effect (“How are they better off?”)

  • Percent of clinic-based social service integration initiatives that are designed and implemented with an explicit focus on the multiple causes of poor health outcomes (Indicates the prioritization of comprehensive integration efforts)
  • Percent of clinic-based social service integration efforts that are sustainably funded and resourced for long-term impact and continuity. (Shows the financial and institutional commitment to integrated care)
  • Percent reduction in negative health outcomes experienced by children and families in the community served by integrated clinics. (Indicates the population-level impact of integration on reducing service gaps)
  • Percent of children and families who access and utilize needed social services as a result of clinic-based integration efforts. (Shows the effectiveness of service linkages and coordination)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] King 2006 - King G, Meyer K. Service integration and co-ordination: A framework of approaches for the delivery of co-ordinated care to children with disabilities and their families. Child: Care, Health, and Development. 2006;32(4):477-492.

2 Fichtenberg 2020 - Fichtenberg C, Delva J, Minyard K, Gottlieb LM. Health and human services integration: Generating sustained health and equity improvements. Health Affairs. 2020;39(4):567-573.

3 GI-Integration 2014 - Governing Institute (GI), KPMG Government Institute. The integration imperative as the driver of reform: US state and local government innovations in human and social services delivery. 2014.

4 Cheng 2019 - Cheng S, Catallo C. Case definition for health and social care services integrated initiatives. Journal of Integrated Care. 2019;27(4):264-275.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.