Why Health Care Must Bridge Social Services

Michael visited emergency departments 85 times in just over a year, cycling between 4 major hospitals in Southern New Jersey. Each visit addressed his immediate medical needs, but nothing changed his underlying reality or addressed his goals of getting help with employment and housing. It wasn’t until a coordinated case conference brought together health care providers and behavioral health specialists to develop a collaborative plan of care that a behavioral health navigator was able to connect with Michael and provide intensive support beyond the hospital walls. This included a connection to short-term housing, support stabilizing his medications, and linkage to long-term care. His visits to the emergency department dramatically declined following the case conference.

"The fragmentation between clinical care and social services isn’t just inefficient; it’s harmful. And as potential cuts to health and social programs loom, bridging this divide becomes even more urgent." | Image credit: C Davids/peopleimages.com - stock.adobe.com

Michael’s story, highlighted in a program implementation guide published by The Camden Coalition, illustrates a critical truth: our health care system is designed to treat discrete medical problems, not to address the complex interplay of health and social factors driving poor outcomes. The fragmentation between clinical care and social services isn’t just inefficient; it’s harmful. And as potential cuts to health and social programs loom, bridging this divide becomes even more urgent.

The consequences of siloed systems and inaction extend far beyond inefficient resources. When health care and social services operate in isolation, vulnerable individuals fall through the cracks. A patient may receive excellent medical treatment in a hospital or walk-in clinic but return to unstable housing or food insecurity, virtually guaranteeing a decline in their health. When shelters are full or feel unsafe and there is nowhere else to go to find rest and warmth at 2AM, the emergency department often becomes the only accessible refuge. In fact, previous research has found that social determinants account for up to 80% of health outcomes.

To address some of these complex needs, integrated approaches that reach people both at the time of their visit and back in the community are a must. The Camden Coalition has pioneered 2 such pilots that may serve as models for replication in other health care systems across the country.

First, the Medical-Legal Partnership embeds attorneys directly into addiction treatment settings. When someone is seeking treatment, facing eviction, having insurance benefits denied, or facing a criminal charge can all be barriers to making it to their appointments. With the help of this partnership, patients gain access to free representation that can address the full spectrum of criminal and civil issues that impede recovery. A recent evaluation found that the program resolved at least 1 critical legal issue for 61% of participants that threatened to impact recovery and that 75% of participants achieved significant progress in their recovery.

Second, the Pledge to Connect program places behavioral health navigators from local Certified Community Behavioral Health Clinics into emergency departments. The preliminary results show promise, as 100% of patients who accepted support from a navigator were scheduled for intake appointments, with 51% following through and attending their appointment within a median of 5 days of their hospital visit. This connection to treatment helps reduce individuals from cycling through emergency services. As a next step, the Camden Coalition is utilizing our Health Information Exchange—a data platform that receives data from nearly 50 health and social service agencies across South Jersey—to proactively identify individuals who visit multiple emergency departments for behavioral health needs. These patients are then assigned to a navigator for follow-up, and their cases are reviewed during regional case conferences, where health systems and behavioral health providers from across South Jersey agree on a shared care plan with a central point of contact.

Both technology and human connection are essential in establishing effective and sustainable integration models. Connected data systems enable providers to see a full picture of a patient’s clinical and social needs, revealing patterns that are often hidden in isolated systems. When emergency departments, primary care, and social services share information, they can better coordinate care for all patients, especially ones that frequently visit multiple systems. Equally important is authentic teaming across sectors. Embedding community services—for example, behavioral health navigators, attorneys, or peer support specialists—into health care settings is one way to ensure patients can receive services where they already are, with continuity past the hospital walls and back into their community setting. This also helps create teams that understand both formal health care structures and informal community resources to provide culturally responsive assistance that traditional systems often cannot deliver.

To move health care integration from promising pilots to widespread adoption, 2 fundamental shifts are essential. First, we must transform our payment systems. The current fragmentation in health care reflects disjointed funding streams. Fee-for-service models that focus exclusively on clinical services reward volume over outcomes and discourage addressing social factors that drive health care utilization. Value-based payment approaches may provide flexibility to address whole-person needs, including housing, nutrition, and legal services. Performance incentive programs like the New Jersey Quality Improvement Program can encourage hospitals to focus on supporting patients in connecting to services following an emergency department or hospital visit but only financially benefit the hospital with no support for community-based services that are critical to achieving those metrics. New Jersey’s new Housing Supports program, which will reimburse housing assistance providers with Medicaid dollars through an 1115 waiver, is one step toward a sustainable mechanism for community providers to provide holistic support to individuals seeking care alongside health care providers.

Second, we need infrastructure that enables cross-sector collaboration. This includes not just shared data systems but also mechanisms for easily pushing key care coordination tools like shared care plans into individual electronic health systems. To do this, there needs to be trust built across competing health and community partners. There is also a need for backbone agencies to strengthen the ecosystem of care by acting as neutral partners that bring together competing systems to create accountability for shared outcomes and provide opportunities for collaboration.

Some may argue integration is too complex or costly, but the status quo of cycling vulnerable individuals through emergency services without addressing root causes is far more expensive, from both a financial and human suffering lens.

When integration works, it truly is transformative. With integrated care, a person experiencing homelessness will receive not only medical treatment but also housing support. A parent struggling with addiction gets treatment alongside parenting support and legal assistance. A person seeking care in the emergency room for a panic attack meets a navigator who helps take them to the pharmacy the next day and connects them to counseling in their community.

The models for bridging social services with health care already exist, and the preliminary evidence is clear, with lots of opportunity for further evaluation. It is now high time that we further break down the silos and create integrated systems that cohesively respond to the complex and diverse needs of patients.

Author Bios

Kevan Shah, MSc, MSM, is an MD candidate at Cooper Medical School of Rowan University. He is the founder and executive director of End Overdose Together. Views expressed are my own and do not reflect those of affiliated organizations

Leigh Wilson-Hall, MSW, is the Director of Care Management & Redesign Initiatives at the Camden Coalition.

Jubril Oyeyemi, MD, FHELA, is the Chief Medical Officer of the Camden Coalition, the Medical Director of the Community Health Institute at Virtua Health, and the Founder and CEO of the Cherry Hill Free Clinic.