The Collaborative to Advance Social Health Integration: What We’re Learning About Delivering Whole-Person Care (2020)

Supported by Health Leads and The Commonwealth Fund, the Collaborative to Advance Social Health Integration (CASHI) was a community of 21 innovative primary care teams and community partners committed to increasing the number of patients, families and community members who have access to the essential resources they need to be healthy. This was accomplished through focused efforts to improve social health practices, spread them to additional sites, and work toward financial sustainability plans.

More broadly, CASHI was created to develop implementation guidance in areas where social health integration know-how was limited but critical for effective delivery of whole-person care. CASHI focused on four core areas:

1. Accelerate practice on key drivers of health equity including patient/community engagement, community health worker (CHW) integration and support, and cross-sector collaboration.
2. Test patient-reported outcome measures (PROMs), which are required to measure social health impact, but difficult to collect and report.
3. Plan for financial sustainability by creating an enduring and practical process for business case development.
4. Move beyond pilots to spread essential resource navigation as an integrated part of care across many sites.

CASHI brought several key successes:

  • Teams dramatically accelerated quality improvement; 90% of teams tested and implemented changes in three or more areas key to social health integration like bolstering effective staffing, training, technology, and screening/assessment approaches.
  • By testing patient-reported outcome measures, they both explored new ways of measuring meaningful impact, and generated evidence of a relationship between resource navigation and health confidence, and therefore health and health equity.
  • Collectively, 15 teams spread their social health approach to over 70 new clinics in just 18 months, demonstrating an unprecedented level of spread over a short time period.
  • Teams applied a practical framework to build a business case, demonstrating value with multiple lenses – not only cost reduction, but also areas like more appropriate use of primary care, increased new patient referrals from community partners, improved provider satisfaction and mission alignment. Rigorous cost analysis also pushed thinking on more efficient ways of operating to support sustainability and expansion.

But most importantly, the work undertaken by the participating health systems laid the foundation for critical practices to move beyond “addressing social needs” to supporting health equity more directly.