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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE: MOVING UPSTREAM TO IMPROVE THE NATION’S HEALTH Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health Board on Health Care Services Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW  Washington, DC 20001 This activity was supported by agreements between the National Academy of Sciences and Archstone Foundation; Association of Oncology Social Work; Bader Philanthropies; Chicago Community Trust; Community Memorial Foundation; Council on Social Work Education; Episcopal Health Foundation; Health Foun- dation of Western and Central New York; Healthy Communities Foundation; Helen Rehr Center for Social Work Practice; Josiah Macy Jr. Foundation; Kaiser P ­ ermanente National Community Benefit; National Association of Social ­ orkers W (NASW) and NASW Foundation; New York Community Trust; Robert Wood Johnson Foundation; SCAN Foundation; and Society for Social Work Leadership in Health Care. Additional support was obtained from the Boston University Center for Innova- tion in Social Work and Health social work academic program match campaign. Contributing academic programs were Adelphi University School of Social Work; Baylor University Diana R. Garland School of Social Work; Binghamton Univer- sity SUNY College of Community and Public Affairs Department of Social Work; Boston College School of Social Work; Brown School at Washington University in St. Louis; California Association of Deans and Directors of Social Work Programs; Case Western Reserve University Jack, Joseph, and Morton Mandel School of Applied Social Sciences; Clark Atlanta University Whitney M. Young, Jr., School of Social Work; Colorado State University–Pueblo, Department of Social Work; Colorado State University School of Social Work; Columbia University School of Social Work; Erikson Institute Graduate School in Child Development; Fordham University Graduate School of Social Service; Georgia State University School of Social Work; Howard University School of Social Work; Long Island University Social Work, Brooklyn and Post campuses; Loyola University Chicago School of Social Work; Monmouth University School of Social Work; New York State Association of Deans and Directors of Schools of Social Work; New York Uni- versity Silver School of Social Work; North Carolina State University School of Social Work; Portland State University School of Social Work; Rutgers Univer- sity School of Social Work; Saint Louis University School of Social Work; Salem State University School of Social Work; San Diego State University School of Social Work; Simmons University School of Social Work; Smith College School for Social Work; Springfield College School of Social Work; St. Louis Group for ­ Excellence in Social Work Research and Education; Stephen F. Austin State Uni- versity School of School Work; SUNY Stony Brook School of Social Welfare; The Ohio State University College of Social Work; The University of Alabama School of Social Work; The University of Chicago School of Social Service Administra- tion and Center for Health Administration Studies; The University of Southern Mississippi School of Social Work; The University of Texas at Arlington School of Social Work; The University of Utah College of Social Work; University at ­ lbany A SUNY School of Social Welfare; University at Buffalo SUNY School of Social Work; University of California, Berkeley, School of Social Welfare; University of California, Los ­ ngeles, Luskin School of Public Affairs Department of Social A Welfare; University of Cincinnati School of Social Work; University of Connecticut PREPUBLICATION COPY—Uncorrected Proofs

School of Social Work; University of Georgia School of Social Work; University of Hawaii at Manoa Myron B. Thompson School of Social Work; University of Houston Graduate College of Social Work; University of Illinois at Chicago Jane Addams College of Social Work; University of Kentucky College of Social Work; University of Louisville Kent School of Social Work; University of Maryland ­ School of Social Work; University of Michigan School of Social Work; University of Missouri School of Social Work; University of North Carolina at Chapel Hill School of Social Work; University of North Carolina at Charlotte School of Social Work; University of Oklahoma Anne and Henry Zarrow School of Social Work and Center for Social Work in Healthcare; University of Pittsburgh School of Social Work; University of South Carolina College of Social Work; University of South Florida School of Social Work; University of Southern California Suzanne Dworak–Peck School of Social Work; University of Washington School of Social Work; University of Wisconsin–Milwaukee Helen Bader School of Social Welfare; University of Wisconsin–Whitewater Department of Social Work; and Westfield State University Department of Social Work. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: International Standard Book Number-10: Digital Object Identifier: https://doi.org/10.17226/25467 Library of Congress Control Number: Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health. Washington, DC: The National Academies Press. https://doi. org/10.17226/25467. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE ON INTEGRATING SOCIAL NEEDS CARE INTO THE DELIVERY OF HEALTH CARE TO IMPROVE THE NATION’S HEALTH KIRSTEN BIBBINS-DOMINGO (Chair), Lee Goldman, M.D., Endowed Chair in Medicine; Professor and Chair, Department of Epidemiology and Biostatistics, University of California, San Francisco TOYIN AJAYI, Chief Health Officer, Cityblock Health TAMARA CADET, Associate Professor, School of Social Work, Simmons University LISA A. COOPER, Bloomberg Distinguished Professor, James F. Fries Professor of Medicine, Director, Johns Hopkins Center for Health Equity, Johns Hopkins University School of Medicine and Bloomberg School of Public Health KAREN DeSALVO, Professor of Medicine, The University of Texas at Austin, Dell Medical School CHRIS ESGUERRA, Senior Medical Director, Blue Shield of California JANET C. FRANK, Adjunct Associate Professor, Faculty Associate, University of California, Los Angeles (UCLA) Center for Health Policy Research, UCLA Fielding School of Public Health RACHEL GOLD, Senior Investigator, Kaiser Permanente Northwest Center for Health Research and Lead Research Scientist, OCHIN ROBYN GOLDEN, Associate Vice President, Population Health and Aging, Rush University Medical Center LAURA GOTTLIEB, Director, Social Interventions Research and Evaluation Network, Department of Family and Community Medicine, University of California, San Francisco SEAN JOE, Benjamin E. Youngdhal Professor of Social Development, Brown School, Washington University in Saint Louis CHRISTOPHER KOLLER, President, Milbank Memorial Fund CINDY MANN, Partner, Manatt, Phelps & Phillips, LLP DIANA J. MASON, Senior Policy Service Professor, Center for Health Policy and Media Engagement, School of Nursing, The George Washington University KEDAR MATE, Chief Innovation and Education Officer, Institute for Healthcare Improvement EDWARD SALSBERG, Director of Health Workforce Studies, Health Workforce Institute, The George Washington University vi PREPUBLICATION COPY—Uncorrected Proofs

ELIZABETH CUERVO TILSON, State Health Director and Chief Medical Officer, North Carolina Department of Health and Human Services KEEGAN WARREN-CLEM, Director, Austin Medical–Legal Partnership, Texas Legal Services Center and People’s Community Clinic Study Staff ABIGAIL MITCHELL, Study Director MEGAN KEARNEY, Associate Program Officer ANNALEE GONZALES, Administrative Assistant MICAH WINOGRAD, Financial Officer SHARYL NASS, Director, Board on Health Care Services Consultants AMBER HALEY, Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill ALLISON MYERS, Director, Oregon State University Center for Health Innovation  Editorial Consultant ROBERT POOL vii PREPUBLICATION COPY—Uncorrected Proofs

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Reviewers T his Consensus Study Report was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical exper- tise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integ- rity of the deliberative process. We thank the following individuals for their review of this report: JEFFERY BRENNER, UnitedHealthcare KARINA W. DAVISON, Northwell Health KAREN DONELAN, Health Policy Research Center at the Mongan Institute, Harvard Medical School ERIN P. FRAHER, University of North Carolina at Chapel Hill School of Medicine LAURAN HARDIN, National Center for Complex Health and Social Needs, Camden Coalition PETER MARAMALDI, Simmons School of Social Work and Harvard T.H. Chan School of Public Health HEATHER A. McCABE, Indiana University School of Social Work VICTORIA M. RIZZO, University at Albany State University of New York School of Social Welfare ix PREPUBLICATION COPY—Uncorrected Proofs

x REVIEWERS NIRAV R. SHAH, Stanford University KATHERINE SWARTZ, Harvard T.H. Chan School of Public Health ELLEN-MARIE WHELAN, Centers for Medicare & Medicaid Services Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclu- sions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by SUSAN CURRY, The University of Iowa, and BRADFORD H. GRAY, Urban In- stitute. They were responsible for making certain that an independent ex- amination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments W e, the members of the National Academies of Sciences, Engi- neering, and Medicine’s Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health, wish to express our sincere gratitude to the many individuals and groups who helped with this report. Our work would not have been possible without the generosity of the sponsors. We would like to thank Archstone Foundation, Association of Oncology Social Work, Bader Philanthropies, Chicago Community Trust, Community Memorial Foundation, Council on Social Work Education, Episcopal Health Foundation, Health Foundation of Western and Central New York, Healthy Communities ­ oundation, Helen Rehr Center for Social F Work Practice, Josiah Macy Jr. Foundation; Kaiser Permanente National ­ Community Benefit; National Association of Social Workers (NASW) and NASW Foundation; New York Community Trust; Robert Wood Johnson Foundation; SCAN Foundation; and Society for Social Work Leadership in Health Care. We also would like to thank the social work academic pro- grams that contributed to this work through a match campaign sponsored by Boston University Center for Innovation in Social Work and Health: Adelphi University School of Social Work Baylor University Diana R. Garland School of Social Work Binghamton University SUNY College of Community and Public Affairs Department of Social Work Boston College School of Social Work Brown School at Washington University in St. Louis xi PREPUBLICATION COPY—Uncorrected Proofs

xii ACKNOWLEDGMENTS California Association of Deans and Directors of Social Work Programs Case Western Reserve University Jack, Joseph, and Morton Mandel School of Applied Social Sciences Clark Atlanta University Whitney M. Young, Jr., School of Social Work Colorado State University–Pueblo, Department of Social Work Colorado State University School of Social Work Columbia University School of Social Work Erikson Institute Graduate School in Child Development Fordham University Graduate School of Social Service Georgia State University School of Social Work Howard University School of Social Work Long Island University Social Work, Brooklyn and Post campuses Loyola University Chicago School of Social Work Monmouth University School of Social Work New York State Association of Deans and Directors of Schools of Social Work New York University Silver School of Social Work North Carolina State University School of Social Work Portland State University School of Social Work Rutgers University School of Social Work Saint Louis University School of Social Work Salem State University School of Social Work San Diego State University School of Social Work Simmons University School of Social Work Smith College School for Social Work Springfield College School of Social Work St. Louis Group for Excellence in Social Work Research and Education Stephen F. Austin State University School of School Work SUNY Stony Brook School of Social Welfare The Ohio State University College of Social Work The University of Alabama School of Social Work The University of Chicago School of Social Service Administration and Center for Health Administration Studies The University of Southern Mississippi School of Social Work The University of Texas at Arlington School of Social Work The University of Utah College of Social Work University at Albany SUNY School of Social Welfare University at Buffalo SUNY School of Social Work University of California, Berkeley, School of Social Welfare PREPUBLICATION COPY—Uncorrected Proofs

ACKNOWLEDGMENTS xiii University of California, Los Angeles, Luskin School of Public Affairs Department of Social Welfare University of Cincinnati School of Social Work University of Connecticut School of Social Work University of Georgia School of Social Work University of Hawaii at Manoa, Myron B. Thompson School of Social Work University of Houston Graduate College of Social Work University of Illinois at Chicago Jane Addams College of Social Work University of Kentucky College of Social Work University of Louisville Kent School of Social Work University of Maryland School of Social Work University of Michigan School of Social Work University of Missouri School of Social Work University of North Carolina at Chapel Hill School of Social Work University of North Carolina at Charlotte School of Social Work University of Oklahoma Anne and Henry Zarrow School of Social Work and Center for Social Work in Healthcare University of Pittsburgh School of Social Work University of South Carolina College of Social Work University of South Florida School of Social Work University of Southern California Suzanne Dworak–Peck School of Social Work University of Washington School of Social Work University of Wisconsin–Milwaukee Helen Bader School of Social Welfare University of Wisconsin–Whitewater Department of Social Work Westfield State University Department of Social Work We are grateful to the Gordon and Betty Moore Foundation and to the National Academy of Medicine’s Culture of Health Program for pro- viding financial support for report dissemination and communications efforts. Over the course of the study, we received valuable information and insight from a number of individuals with expertise in fields related to health-related social care. Thank you to the presenters at our public meetings: Sara Bachman, Boston University School of Social Work Michelle Brazeal, Mississippi Integrated Health and Disaster Program and The University of Southern Mississippi Darla Spence Coffey, Council on Social Work Education PREPUBLICATION COPY—Uncorrected Proofs

xiv ACKNOWLEDGMENTS Kelly Craig, Camden Coalition of Healthcare Providers Jolene Fassbinder, Archstone Foundation Kathryn Haslanger, JASA Reverend Debra Hickman, Sisters Together and Reaching, Inc. Kristie Kulinski, Administration for Community Living, U.S. Department of Health and Human Services Natasha Lifton, New York Community Trust Angelo McClain, National Association of Social Workers Susan Mende, Robert Wood Johnson Foundation Tim Rehner, School of Social Work, The University of Southern Mississippi Susan Reinhard, AARP Public Policy Institute Victoria M. Rizzo, School of Social Welfare, University at Albany SUNY Walter Rosenberg, Social Work and Community Health, Rush University Medical Center Loel Solomon, Kaiser Permanente National Community Benefit Laura Taylor, Veterans Health Administration, U.S. Department of Veterans Affairs Roberta Waite, College of Nursing and Health Professions, Drexel University and Stephen and Sandra Sheller 11th Street Family Health Service Michelle M. Washko, National Center for Health Workforce Analysis, Health Resources and Services Administration, U.S. Department of Health and Human Services Randi Woods, Sisters Together and Reaching, Inc. We also thank Dave Chokshi, NYC Health + Hospitals, and Louise Cohen and Riley Moreen, Primary Care Development Corporation, for providing information to the committee at its request. We appreciate the considerable efforts of Bonnie Ewald, Rush Uni- versity Medical Center, and of the Social Work in Health Care Leadership Workgroup convened by the Center for Health and Social Care Integra- tion, who were instrumental in conceiving the idea for the study and working to move it forward. In addition to the study staff, we would like to thank National Academies’ staff members Daniel Bearss1 and Jorge Mendoza-Torres for their research assistance, Kyra Cappelucci and Greta Gorman for their oversight of report communications efforts, and Karen Helsing for her assistance with fundraising for the study. 1 Daniel Bearss passed away on July 5, 2019. A senior librarian at the National Academies since 2005, his assistance with literature searches and other research for this report was invaluable. PREPUBLICATION COPY—Uncorrected Proofs

Contents SUMMARY 1 1 INTRODUCTION 19 2 FIVE HEALTH CARE SECTOR ACTIVITIES TO BETTER INTEGRATE SOCIAL CARE 33 3 A WORKFORCE TO INTEGRATE SOCIAL CARE INTO HEALTH CARE DELIVERY 59 4 LEVERAGING DATA AND DIGITAL TOOLS 85 5 FINANCING SOCIAL CARE 109 6 IMPLEMENTING AWARENESS, ADJUSTMENT, AND ASSISTANCE STRATEGIES IN HEALTH CARE DELIVERY SETTINGS: CHALLENGES AND POTENTIAL SOLUTIONS 137 7 RECOMMENDATIONS 163 APPENDIX: SOCIAL NEED SCREENING TOOLS COMPARISON TABLE 173 xv PREPUBLICATION COPY—Uncorrected Proofs

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The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend – at least in part – on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients’ social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities.

Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.

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