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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health (2019)

Chapter: 3 A Workforce to Integrate Social Care into Health Care Delivery

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Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 63
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 64
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 65
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 66
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 67
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 68
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 69
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 70
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 71
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 75
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 80
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 81
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 82
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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 83
Suggested Citation:"3 A Workforce to Integrate Social Care into Health Care Delivery." 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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3 A Workforce to Integrate Social Care into Health Care Delivery W orkforce availability and the competence of workers to serve the needs of complex vulnerable populations and address ad- verse social determinants of health (SDOH), is not a new subject for the National Academies of Sciences, Engineering, and Medicine (the National Academies). Among the National Academies reports that have addressed this topic are Retooling for an Aging America: Building the Health Care Workforce (IOM, 2008), The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (IOM, 2012b), Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes (IOM, 2015), A Framework for Educating Health Professionals to Address the Social Determinants of Health (NASEM, 2016a), Strengthening the Workforce to Support Community Living and Participation for Older Adults and Indi- viduals with Disabilities (NASEM, 2017), and Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health (Long et al., 2017). In addition, reports produced by the U.S. Department of Health and Human Services, such as Addressing the Social Determinants of Health: The Role of Health Professions Education (Committee on Training in Primary Care Medicine and Dentistry, 2016), shed light on the critical issues of the role of the workforce in addressing social determinants and provide recommendations for improvement. Collectively, these reports establish the foundation required to discuss how to best prepare and support a workforce to address the social needs of populations as one component of health care delivery. Evidence linking the SDOH with a population’s health status and health care costs has led to efforts to redesign health care and to better 59 PREPUBLICATION COPY—Uncorrected Proofs

60 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE link the provision of health care with the provision of social services in ways that address the factors that contribute to the poor health of pa- tients and communities. Chapter 2 identified five complementary activi- ties that health care systems can adopt in order to strengthen social care integration: awareness, adjustment, assistance, alignment, and advocacy. Implementing and sustaining efforts within each of the five activities will require making systems-level changes, including the development of a well-trained workforce with defined roles, innovations in data and digital tools, and new financing models. This chapter focuses on the necessary elements of a workforce that will have the capability and capacity to im- prove social care within these five activities. THE PROMISE OF INTERPROFESSIONAL TEAMS IN IMPROVING SOCIAL CARE There is a consensus among agencies and organizations as well as among educators and clinicians that addressing the adverse SDOH is complex and requires an interprofessional team (NASEM, 2016b). Team- work in health care has been associated with improvements in knowl- edge, practice, and such outcomes as quality, cost reduction, and job satisfaction (Medves et al., 2010). Effective collaboration among teams requires explicitly defined tasks and goals, clear and meaningful roles for each individual, and systematic guidelines to assist practitioner in their decision making. The use of in-person and technology-based mechanisms to minimize gaps in care and to avoid duplication of services is important since many team members may be working remotely from one another. The processes that are important in optimizing the functioning of a team include collaboration and coordination, the pooling of resources, and role blurring, which is defined as creating a shared body of knowledge and skills among team members so that various elements of professionals’ roles can be taken on by others, if necessary (Sims et al., 2015). Tackling the complex social needs of patients and families requires collaboration, both on the team and outside of the traditional health care sector, such as on the staffs of social service and public health agencies and community-based organizations.1 As such, the list of individuals who may be considered team members has been expanding. For example, lawyers have become critical team members for addressing legal matters related to housing and other social factors among patients in community 1 As detailed below, types of workers who provide social care can include nurses; physi- cians; social workers; community health workers; social service navigators, aides, assistants, and trained volunteers; home health aides; personal care aides; family caregivers; case managers; gerontologists; lawyers; and others. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 61 health centers (Regenstein et al., 2018). As more organizations and payers address social needs, competencies should be established to ensure that interprofessional teams are equipped to work together optimally within the complex and shifting landscape of social care. The competencies es- tablished for behavioral and primary care workers are an example of how competencies can be used for interprofessional teams (Hoge et al., 2014). How effectively interprofessional teams are able to carry out their day-to-day work is dependent on several factors that, if not taken into account, can hamper integration and collaboration among team members. One such important factor is role clarity—that is, how well team members know their own and the other’s roles and responsibilities (Ambrose- Miller and Ashcroft, 2016; Sims et al., 2015). Social needs are best ad- dressed when members of the interprofessional team understand the role that each team member plays, both directly and indirectly, in the aware- ness, adjustment, assistance, alignment, and advocacy activities described in Chapter 2. Team members should understand the knowledge, skills, and competencies that each member brings, and each member should be able to work at the full scope of his or her knowledge, skills, and compe- tencies (Glaser and Suter, 2016; Lombardi et al., 2017; Sims et al., 2015). Other factors aiding in the effective functioning of interprofessional teams include allowing team members to maintain their professional identities, particularly in the case of social care workers who work within health care (Garfield and Kangovi, 2019), and addressing issues related to power dynamics among team members (Ambrose-Miller and Ashcroft, 2016). Attributes of successful interprofessional teams include a commitment by staff members to work in a team environment, communication among the staff, and the ability of staff members to come up with creative ways to conduct their work (Molyneux, 2001). According to Sims and colleagues Teams are complex entities influenced by human and organizations fac- tors and the field of health they operate in. This makes teamworking highly variable and context dependent, which means that different teams will succeed in different situations depending upon the processes, par- ticipants, and context in which they are based. (Sims et al., 2015, p. 20) Interprofessional education—defined as “when students from two or more professions learn about, from, and with each other to enable effec- tive collaboration and improve health outcomes” (WHO, 2010a, p. 7)—is an important approach to developing effective interprofessional teams that can address the integration of social care into health care. Recommen- dations from both the Institute of Medicine’s (IOM’s) Health Professions Education: A Bridge to Quality report and the Interprofessional Education Collaborative have called for curriculum and learning activities designed PREPUBLICATION COPY—Uncorrected Proofs

62 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE to develop competencies among health care and social service profession- als in the delivery of patient-centered team care (IOM, 2003a; IPEC, 2011). More educational institutions are developing and providing core cur- ricula to health care and social service providers. Some professions have embraced the need for interprofessional team collaboration to assure that their workers are equipped with the skills, knowledge, and abilities necessary to provide effective team care and to address the social needs of patient populations. The most effective interprofessional education programs combine coursework with clinical and service learning experi- ences in the community (Greer et al., 2018; Siegel et al., 2018; Zomorodi et al., 2018). For example, physicians accompanying a social worker on home visits typically come away with a new appreciation for how the social needs that were identified could compromise the care plan they had in mind (Fulmer et al., 2004). The pathway from initial education to practice behaviors is complex (see Figure 3-1) (IOM, 2015). In considering how best to develop a health FIGURE 3-1  The interprofessional learning continuum model. NOTE: For this model, “graduate education” encompasses any advanced formal or supervised health professions training taking place between the completion of foundational education and entry into unsupervised practice. SOURCE: IOM, 2015. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 63 care workforce that understands and can take into account social factors, it is important to recognize that a health worker’s ability to address social needs can be affected by various external factors. Among the factors that can influence the training of health care workers and their delivery of care are the professional and institutional cultures in which they train and work as well as various workforce and financial policies. The conceptual model shown in Figure 3-1, which assumes interprofessional education to be the gold standard for health and social service training, includes the education-to-practice continuum and a broad array of learning, health, and system outcomes, and it shows the major enabling and interfering factors that affect the education-to-practice pathway. This model was put forth with the understanding that it requires empirical testing and that it may have to be adapted to the particular settings in which it is applied. The development and implementation of effective interprofessional team training programs face a number of challenges. For example, a na- tional evaluation of the John A. Hartford Foundation’s Geriatric Interdis- ciplinary Team Training program found that the attitudinal and cultural traditions of the different health professions faculty and students (usually split along disciplinary lines) are important obstacles to creating an op- timal interdisciplinary team training experience (Reuben et al., 2004). In general, physician trainees participated least enthusiastically in geriatric interdisciplinary team training. Among the other challenges to estab- lishing effective interprofessional team training programs are various logistical issues, such as dealing with differences in educational calendars among the different professions and class schedules. At the heart of the challenge in installing team-based approaches as a key part of profes- sional education is what Frenk and colleagues referred to as “tribalism of the professions—that is, the tendency for the various professions to act in isolation from or even in competition with each other” (Frenk et al., 2010, p. 1923). THE TRADITIONAL HEALTH CARE WORKFORCE As noted above, effectively addressing people’s complex social needs requires that workers within the traditional health care system collabo- rate with workers from outside of it, such as the staff of social service and public health agencies and community-based organizations. This team approach is not one size fits all. The composition of teams can vary depending on such factors as the available resources (e.g., human, tech- nological, and financial resources), the circumstances (e.g., urban versus rural location), and importantly, which of the five activities (awareness, adjustment, assistance, alignment, and advocacy) is being addressed. An awareness of the SDOH and social care is essential. Just as established PREPUBLICATION COPY—Uncorrected Proofs

64 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE competencies and training measures ensure that professionals within the social care landscape can work together and communicate effectively, it is crucial that traditional health care workers know about social care. Health professional organizations are increasingly interested in adding curricular content on addressing the SDOH to health professional education (HRSA, 2016). The competencies related to the SDOH include cultural humility, reflection, advocacy, cultural competency, partnership skills, patient com- munication, and empathy. The nursing profession has long focused on the social needs of people and communities (Buhler-Wilkerson, 1993; Fee and Garofalo, 2010). Acute care nurses are expected to also address the psychosocial needs of pa- tients, whether through referrals to social workers or care managers or as part of the discharge planning process. Some nurses are care managers and have great involvement in addressing social needs within health care delivery. Home care nurses assess patients’ and families’ social needs and may refer patients who have complex social needs to social workers. Nurses in home visitation programs for high-risk mothers and children, such as the Nurse-Family Partnership, address social supports, employ- ment, education, and various other aspects of the mothers’ lives such as how to reduce contact with the criminal justice system. These activities are important to short- and long-term maternal and child outcomes (Olds et al., 2007; Williams et al., 2008). Other examples of nurse-designed models of care that successfully integrate the social needs of individuals and fami- lies have been documented in a 2018 RAND report (Martsolf et al., 2017). In its 2008 report The Essentials of Baccalaureate Education for Profes- sional Nursing Practice, the American Association of Colleges of Nursing (AACN) defined the essentials of a baccalaureate education in nursing, noting that programs are expected to educate graduates who can “apply knowledge of social and cultural factors to the care of diverse popula- tions” (AACN, 20008, p. 12) and “facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowl- edge of care requirements to promote safe care” (AACN, 2008, p. 31). The AACN commissioned a “visioning” task force for defining the future of nursing education. The resulting vision includes educating nurses about the SDOH, and this is expected to be included in the next version of The Essentials of Baccalaureate Education for Professional Nursing Practice.2 The National League for Nursing intends to undertake similar work to include the SDOH and social care in its recommendations for nursing curricula.3 Physicians, particularly those working in primary care (includ- ing internal medicine, pediatrics, geriatrics, and family medicine) are 2 Personal communication, Deborah Trautman, American Association of Colleges of Nurs- ing, October 17, 2018. 3 Personal communication, Beverly Malone, National League for Nursing, October 1, 2018. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 65 increasingly expected to recognize the role of social risk factors and social needs in the prevention and treatment of illness and disability. No sys- tematic studies have been done, however, to determine the prevalence of physicians’ awareness of or engagement in social care integration or what types of physicians may use which types of activities more frequently. For those physicians who have completed medical school and are in postgraduate training, the Accreditation Council for Graduate Medical Education has identified several competencies that support physician involvement in addressing patients’ social needs. Some of the competen- cies are related to awareness activities, such as being able to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds. Others of the competencies are related to assistance activities , such as the ability to work in interprofessional teams to enhance patient safety and improve patient care quality; having sensitivity and responsiveness to a diverse patient population, including, patients diverse in gender, age, culture, race, religion, disabilities, and sexual orientation; and being able to work effectively as members or leaders of a health care team or other profes- sional group (ACGME/ABFM, 2015; Cate, 2013; Leipzig et al., 2014; Parks et al., 2014). When physician residency programs do include content on the SDOH, it is largely didactic and provided in short or one-time sessions (Gard et al., 2018). Some residency programs include more extensive content on the SDOH; for example, Florida International University’s Herbert Wertheim College of Medicine has a service-learning experience in the community with an interprofessional team of students (including nursing and pub- lic health) that integrates the SDOH, professional teamwork competen- cies (including nursing and public health), and community collaboration (Greer et al., 2018). There is a growing recognition of the need to include formal education about the SDOH as part of physician training, and some medical schools are calling for a dramatic rethinking of the social mission of medical schools more broadly, including their responsibility to focus educational, research, clinical, and community service efforts on the SDOH, particularly for the communities where they are located (Mullan, 2017). A review of the literature found rising interest in making the SDOH as part of medical education (Doobay-Persaud et al., 2019). Medical education leaders and experts also are supportive of increasing the exposure to the SDOH across the medical education curriculum; do- ing this, however, will require development of a common curriculum, standardizing teaching methods, and standard approaches to evaluating impact (Mangold et al., 2019). PREPUBLICATION COPY—Uncorrected Proofs

66 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE THE SOCIAL CARE WORKFORCE Ideally, all members of an interprofessional team should have a base- line understanding of social care and the SDOH, but that likely will not be sufficient; effectively integrating social care into health care beyond the level of awareness may require developing a workforce with expertise and a scope of work that are specific to social care. The following discus- sion provides information that should be considered when developing interprofessional teams, including details about the necessary skill sets and the key professions involved with providing social care. Depending on the social needs of a particular population, it may make sense to in- clude other professions on the team beyond those discussed below (e.g., clergy, medical interpreters, or oral health providers). The composition of interprofessional teams will vary depending on the model of care. Social Workers There is a long history of professional social workers providing social care within both the health care and social service sectors, and many social workers have expertise in these fields (Gehlert and Brown, 2011). Social workers assess and address the social needs and well-being of people’s lives, whether through direct interventions at the micro level (awareness and assistance activities aimed at the individual and family) or through activities at the meso level (adjustment and alignment activities within the health care system) and macro level (alignment and advocacy at the socio-structural level) (Newman et al., 2015; USC, 2019). Social workers have led efforts to build bridges between the silos of social services and health care through interventions such as care manage- ment and transitional care that take advantage of social work expertise in patient and family engagement, assessment, care planning, behavioral health, and systems navigation (Fraser et al., 2018). By speaking the “lan- guage” of—and understanding the important roles of—both community and medical providers, social workers can play an important role in ensuring effective collaboration and communication across the care con- tinuum. They also lead community-based organizations that focus on the social needs and well-being of individuals and families in communities (Pecukonis et al., 2013). Medical social workers are directly involved with the health of individuals and work in a variety of settings, typically hospitals, outpatient clinics, community health agencies, social service agencies, skilled nursing facilities, long-term care facilities, hospices, and health insurers’ offices. Professional social workers obtain a baccalaureate or master’s de- gree in social work, and master’s-level social workers can seek licensure. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 67 Licensure requirements vary by state, but typically involve an exam and a minimum amount of clinical hours with supervision by a licensed clinical social worker. Social workers’ education and training cover many of the SDOH competencies noted above. For example, the social work profes- sion, through the National Association of Social Work, has developed a number of specialized standards of practice that focus on the needs for clinical services of special populations or within specific care settings (NASW, 2016). Several of these standards are particularly relevant to social care in health care delivery. One notable standard for clinical social work in social work practice is: “Clinical social workers shall be knowl- edgeable about community services and make appropriate referrals, as needed” (NASW, 2005, p. 4). A comprehensive set of standards exists for social work practice done within health care settings, including, for example, Social workers practicing in health care settings shall advocate for the needs and interests of clients and client support systems and promote system-level change to improve outcomes, access to care, and delivery of services, particularly for marginalized, medically complex, or disad- vantaged populations. (NASW, 2016, p. 29) In the area of practice in interprofessional teams, the standards for social workers in health care settings include, for instance, “Social work- ers practicing in health care settings shall promote collaboration among health care team members, other colleagues, and organizations to sup- port, enhance, and deliver effective services to clients and client support systems” (NASW, 2016, p. 31). Community Health Workers Community health workers (CHWs) provide linkages among health, social services, and the community (APHA, 2019). Often recruited from the communities they serve, CHWs work in health systems, social ser- vice agencies, and community-based organizations. There is a growing number of CHWs employed in hospitals and health systems as well (Malcarney et al., 2017). They are engaged in awareness, assistance, and advocacy activities. All but three states have efforts related to integrating CHWs into health care systems (NASHP, 2017). There is growing evidence of their positive impact on health, par- ticularly for low-income and minority patients. Several outcome studies related to the use of CHWs have been conducted. The Penn Center for Community Health Workers developed and tested the IMPaCT model, a standardized and scalable CHW intervention; two clinical trials have PREPUBLICATION COPY—Uncorrected Proofs

68 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE documented the positive effect of the model (Kangovi et al., 2017, 2018). A systematic review of the literature concluded that there is some evidence that the use of community health workers to help care for the chronically ill could reduce the use of health care and costs (Jack et al., 2017). It is important to note, however, that these studies of the role of CHWs in bridging medical and social care did not clearly articulate whether the CHWs’ social care was the component of the intervention that actually achieved health outcomes. Efforts are under way to develop competencies and standardize ed- ucational requirements for CHWs (Rosenthal et al., 2016). The North Carolina Community Health Worker Initiative provides technical assis- tance from CHW experts through the Association of State and Territorial Health Officials with the aims of confirming the roles and competencies of CHWs, standardizing their training and certification, and identifying the infrastructure and policy supports necessary for the effective use of CHWs (NC DHHS, 2019). The global need for such standardization of the CHW role, training, and infrastructure development has been recognized by the World Health Organization (WHO, 2010b). According to a 2003 IOM report, barriers to the integration of CHWs into health care delivery include inconsistencies in the scope of practice, training, and qualifications; a lack of sustainable funding; and insufficient recognition by other health professionals (IOM, 2003b). Certification has been established in a number of states, but the requirements (both educa- tion- and career-wise) vary widely. Training requirements range from 80 hours to 160 hours, with various provisions for “grandfathering” experi- enced CHWs (CDC, 2016). The lack of universal professional standards has been described as part of the rationale for the establishment of the National Association of Community Health Workers, which launched in April 2019 (NACHW, 2019). Social Service Navigators, Aides, and Assistants Social service navigators, aides, and assistants, and also trained vol- unteers often work outside of the health care sector in awareness, assis- tance, and advocacy roles in social service agencies and community-based organizations. Examples include housing and transportation experts, peo- ple who work at food banks, people who provide employment assistance, outreach and enrollment workers, navigators, and trained volunteers. These workers assist patients and families on a wide range of activities and often help them find and access services in the community. There is currently no national certification or credentialing for social service navigators, aides, and assistants, or for trained volunteers. Requirements for these workers vary by state, but the workers typically must have at PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 69 least a high school diploma and must complete a brief period of on-the- job training. Home Health Aides and Personal Care Aides Within the health care sector, home health aides and personal care aides provide extensive social support services to assist older adults and disabled and post-acute care patients in their homes. These direct care workers have close contact with the country’s most disadvantaged pa- tients. Working in the home, they can directly observe a wide variety of their clients’ social needs and then provide this information to other members of the care team. They have an important role to play in the as- sistance activity in providing social care. Family Caregivers People who provide care for their family members (family caregivers) are another critical part of the care team and provide assistance to many individuals. Because they spend time in the home, family caregivers, similar to home health aides and personal care aides, have a valuable perspective on the social needs of patients. In 2015 more than 43 million Americans provided unpaid care to high-need individuals, with an esti- mated 85 percent of them being family members (Family Caregiver Alli- ance, 2016). These caregivers provide a wide range of services, including complex medical–nursing tasks such as managing multiple medications, providing wound care, and using medical-related monitors; assisting with activities of daily living; transportation; and communicating with and visiting with health care providers (Reinhard et al., 2012). Case Managers Case managers (and care managers) work intensively with individu- als with complex social needs, whether in the health care system or with social service agencies. An increasing number are certified, as health care organizations and other employers increasingly require certification for hiring or continuing employment (Tahan et al., 2006). Case managers fo- cus on coordinating the health and social care of patients and work within the spheres of awareness, assistance, and advocacy (at the individual level). They can be based in hospitals, at home care agencies, in skilled nursing and rehabilitation facilities, or with community-based organiza- tions. Case managers also are found in social services agencies, such as foster care agencies, child welfare agencies, senior centers, and homeless PREPUBLICATION COPY—Uncorrected Proofs

70 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE shelters. Often, the role of case managers is filled by licensed clinical social workers and licensed nurses. Promising Additional Professions for Improving Social Care Gerontologists Gerontology is a discipline that holds promise for addressing the social needs of the older adult population. According to the Academy for Gerontology in Higher Education (AGHE), “gerontologists improve the quality of life and promote the well-being of persons as they age within their families, communities, and societies through research, education, and application of interdisciplinary knowledge of the aging process and aging populations” (AGHE, 2019). Functional health and independence are the goals of care for older adults, and therefore addressing social needs is a component of addressing health care needs. AGHE has identi- fied core and contextual competencies that support the roles of gerontolo- gists in the five categories of activities that promote social care as part of health care delivery (AGHE, 2014). Gerontology is not well defined in terms of how it relates to social care. Unlike other types of health and social services disciplines, there is no licensure, scope of work, or U.S. Department of Labor recognition for gerontologists. In 2016 the Accreditation for Gerontology Education Council was established to accredit gerontology education programs at the associate, baccalaureate, and master’s levels. This is an important step in the development of the profession and will further link the AGHE competencies to gerontology education programs and social care practice. According to the National Association for Professional Gerontologists, certified gerontologists report holding such positions as direct service providers (health and community support services), administrators, chief executive officers, entrepreneurs and business owners, therapists and counselors, resource navigators and information specialists, program directors, professors, researchers, pastors, and geriatricians and other medical doctors.4 In certain states, organizations employing gerontolo- gists with at least a bachelor’s degree can be reimbursed for services specified in the waiver agreement with the Centers for Medicare & Med- icaid Services Home and Community-Based Services Program (California Department of Health Care Services, 2019). These services vary by state, but often include a home- and community-based services wellness as- sessment and case management services. Because older adults often have 4 Personal communication, Donna Schaefer, August 29, 2018. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 71 complex medical and social needs, expanding the use of gerontologists in these roles will provide an additional resource for increasing social care. Lawyers Lawyers who address the social needs of patients and families are in- creasingly being used in community-based organizations, including some federally qualified health centers, to assist patients and families with legal matters that can compromise health, such as inadequate housing or a loss of housing. Medical–legal partnerships integrate the unique expertise of lawyers into health care settings in order to help clinicians, social workers, and care managers address the social needs of patients in ways that can reduce many health inequities (Regenstein et al., 2018). There are many different types of lawyers, but one type in particular is relevant to social care: the public interest lawyer. Public interest lawyers work for private, nonprofit organizations that provide legal services to disadvantaged people or others who otherwise might not be able to afford legal representation. They generally handle civil cases, such as those having to do with leases, job discrimination, and wage disputes, rather than criminal cases. (BLS, 2019) Increasing the availability and involvement of public interest lawyers will help in providing social care to the vulnerable populations. CHALLENGES AND BARRIERS FOR SOCIAL CARE WORKERS The social care workforce faces a number of challenges and barriers to practice at the individual level, organizational level, and systems level. More information on the workforce challenges related to integrating so- cial care into the delivery of health care is presented in Chapter 6. Individual worker-level challenges can be divided into several cate- gories: worker health and well-being, including issues related to burnout, violence, and suicide; worker satisfaction, including issues related to com- pensation, incentives, perceived value, and sense of identity; and negative attitudes regarding the SDOH and “blaming the victim” (Bodenheimer and Sinsky, 2014; Bride, 2007; Eelen et al., 2014; Hart and Warren, 2013; Kim et al., 2018; Martin and Schinke, 1998). These individual-level chal- lenges can be worsened by a lack of organizational capacity to address adverse social conditions, which can exacerbate professional burnout, particularly by affecting providers’ self-efficacy (De Marchis et al., 2019; Olayiwola et al., 2018; Pantell et al., 2019). PREPUBLICATION COPY—Uncorrected Proofs

72 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE Organizational-level challenges include issues relating to the hierar- chy of leadership of health and social service professionals and the siloed nature of health care and social services (Ellner and Phillips, 2017), role limitations in care settings (La Motte, 2012), issues relating to work and case load assignments, and the orientations and values of educational institutions (NASEM, 2016a). Systems-level challenges include barriers to reimbursement for cer- tain types of workers (Houston and Mahadevan, 2015; HRSA, 2018a), inadequate numbers of workers, and workforces that are not demo- graphically representative of the populations they serve (Lin et al., 2016; NASEM, 2016a; Warshaw and Bragg, 2014). Medicare payments and policy have substantially influenced medical and clinical social work. In 1989 the Omnibus Budget Reconciliation Act amended the Social Security Act to include clinical social work services under Medicare Part B covered services, defining clinical social work services as services related to the “diagnosis and treatment of mental illnesses” (summarized in Zarrella, 2005). This change enabled licensed social workers to bill Medicare for individual and group psychotherapy, which contributed to social work becoming the largest behavioral health workforce in the United States (Heisler, 2018; Zarrella, 2005). However, this definition of clinical social work is limiting in that it does not reflect the broad array of services that clinical social workers provide, which creates confusion about social work’s scope of practice despite curricula and core competencies that reach beyond behavioral health diagnosis and treatment. As a result, no matter whether they practice indepen- dently, as part of a health care organization, or as part of a commu- nity-based organization, social workers are defined in Medicare only as mental health providers and not as carrying out other roles such as care managers or the providers of psychoeducation which help patients adapt to a new diagnosis. This means that no matter the practice setting, social workers’ work is not adequately captured by Medicare fee-for-service billing options. Importantly, the definition’s exclusive focus on behav- ioral health has largely prevented social workers from using health and behavior assessment and intervention codes for billing, even though it is these codes that reimburse for services that target social factors result- ing from or affecting physical health problems and that are unrelated to a behavioral health diagnosis (NASW, 2016). This billing limitation restricts the ability of health care and community-based organizations to build and sustain interventions that integrate health care and social care to address social needs. Thus, the limitation of social workers’ ability to bill for non-mental–health services in a clinical setting by default limits their scope of practice because other sustainable sources of funding for their services often are not available. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 73 One note of caution is warranted here. Laws and regulations gov- erning a profession’s scope are generated in political environments and steeped in historical contexts. As such, the current policies governing the scope of practice for health professionals may not reflect the emerging interest in integrating social care into health care delivery, in the effec- tive use of interprofessional teams, and in having all health care workers practicing to the top of their education and training (IOM, 2011). This issue of practicing to the top of one’s scope of practice applies to social care workers as well as to traditional health care workers. And emerging workforce professions such as CHWs often have only exclusionary guid- ance on their scope—there are few states that have statutes or regulations defining their scope of practice, so in most states their work is defined by what other professions claim as exclusive territory (CDC, 2016). Individual- and organizational-level challenges and barriers affect recruitment and retention efforts and contribute to workforce shortages. For example, in addition to the general reimbursement and scope-of- practice challenges experienced by social workers, individual states differ in their qualifications for licensure, categories of licensure, and scopes of practice. There is no system of license reciprocity or portability among states, making both professional relocation and the provision of telehealth services difficult. In addition to educating the future health care workforce and train- ing the current workforce about health disparities and the importance of addressing social needs in health care delivery, it is important to make sure that the health care workforce is representative of the demograph- ics of the communities it serves. Substantial variation exists in how well health care and social service occupations reflect the diversity of the U.S. population, with minorities being underrepresented in professions re- quiring master’s level education or higher (HHS, 2017). Employing more underrepresented minority groups in health care may improve how well social care is provided and may better meet the needs of an increasingly diverse U.S. population. Several governmental and nongovernmental bodies have concluded that ensuring that the nation has a diverse health care workforce—especially in terms of gender, cultural, and linguistic representation—is essential (Council on Graduate Medical Education, 2016; HHS, 2006; Wakefield, 2014). Healthy People 2020 sets goals that include eliminating health dispari- ties, addressing the SDOH, and improving access to high-quality health care (HHS, 2010). Achieving these goals will require the use of culturally informed approaches and the hiring of diverse health care and social services professionals and research investigators who possess the ap- propriate knowledge and skills. Additional leadership and professional development programs for faculty and students from underrepresented PREPUBLICATION COPY—Uncorrected Proofs

74 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE minority groups may help to meet these goals and rectify the underrep- resentation of certain demographic groups in the health care workforce. There also is funding for health professions education for minority-serv- ing institutions and underrepresented minorities, including a multitude of programs sponsored by the Health Resources and Services Administra- tion’s Bureau of Health Workforce (HRSA, 2018b). EXAMPLES OF INTERPROFESSIONAL TEAMS THAT ARE ADDRESSING THE FIVE HEALTH CARE SECTOR ACTIVITIES A range of knowledge, skills, and competencies are necessary to address the five health care sector activities—awareness, adjustment, assistance, alignment, and advocacy. Individual activities require inter- professional approaches, but, more to the point, the range of the activities requires an interprofessional workforce. Highlighted below are several examples of how interprofessional teams around the country are provid- ing social care as a part of health care delivery. • Hennepin Health in Minnesota is a health care delivery program formed by joint efforts from the Minnesota Department of Hu- man Services, Hennepin County, and the Northpoint Health & Wellness Center.5 This program seeks to support care delivery reform that can bolster clinical outcomes for patients, both in terms of patient satisfaction and cost. Through multidisciplinary teams, Hennepin Health establishes relationships with patients so its clinicians can best assess the patients’ health risk factors and social needs, allowing them to provide the best care coordination possible. The multidisciplinary teams include both clinical and social care workers to ensure that all lifestyle areas that affect health can be covered. These areas include transportation, nutri- tion, social support, legal, finances, work, and medications. • Care Neighborhood is a program in Northern California in which CHWs reach out to those most at risk to address their social, med- ical, and behavioral health care needs in order to reduce costs and decrease the use of hospitals and emergency departments (EDs).6 Care is delivered by one to two CHWs, who are staff members based at each health center organization and integrated into the medical home team (senior leader champion, social worker, and 5 For more information, see http://www.healthreform.ct.gov/ohri/lib/ohri/1._hennepin- county-medical-center.pdf (accessed on July 15, 2019). 6 For more information, see https://www.careinnovations.org/resources/signature- project-care-neighborhood (accessed on July 15, 2019). PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 75 nurse). These interdisciplinary teams support the CHWs, whose focus is on member relationship and connection to community resources. The program has been implemented at 8 health center organizations with 12 CHW positions within the Care Neighbor- hood Network. Once members have been identified by the em- bedded care team, a clinic-based CHW, with support from a nurse and social worker, assesses and determines next steps. These next steps can include connecting to basic benefits and community resources, connecting to clinic resources and primary care visits, full case management support (navigation, home visits, and care coordination), and integrated behavioral health or housing sup- port services. • The Bridge model of transitional care is an example of a suc- cessful practice-based, cross-disciplinary, and cross-sector care model that addresses social needs (Altfeld et al., 2013; Boutwell et al., 2016; Xiang et al., 2018). Following a hospitalization or re- habilitation stay, Bridge social workers engage with the patient, family members, and inpatient and outpatient providers to en- sure smooth discharges that are attentive to social needs and that reinforce primary care engagement. Bridge’s protocol applies the social work core competencies of patient engagement, person-in- environment (or systems) theory, resource navigation, and psy- chotherapeutic techniques. Bridge places significant emphasis on collaboration across the health and social care continuum, some- times convening all relevant inpatient, primary care, specialty care, community-based, and in-home providers to take part in care continuity calls for particularly complex patients in order to ensure that all the providers understand the patient’s care plan and to troubleshoot any issues that arise. In addition to such hospital-driven programs, staff in community-based organiza- tions across the nation who have been trained in Bridge provide transitional care in partnership with hospitals or skilled nursing facilities. In these hospital–community partnerships, the commu- nity-based organization generally also provides other services that are commonly included in patients’ care plans, such as home- delivered meals or chronic disease self-management classes. The goal is to create a more seamless connection between social care and medical care and thereby to improve health and quality-of- life outcomes for patients and families after an inpatient stay. In various implementation sites with a diverse range of popula- tions, the Bridge model has been found to be associated with increased follow-up with primary care providers, fewer ED visits, and fewer hospital readmissions. Despite these successes, various PREPUBLICATION COPY—Uncorrected Proofs

76 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE challenges, including workforce barriers, exist to scaling up and sustaining these cross-sector, interdisciplinary partnerships. • In an effort to better connect patients with social service agencies that were already available in their area, Geisinger Health System, which operates in parts of Pennsylvania and New Jersey, started a 3-year pilot using community health assistants and social work- ers to improve resource access.7 This program was carried out within 5 counties, assisted 16,000 individuals, and closed 24,000 identified “care gaps” in 3 years. The pilot began with five com- munity health assistants and expanded to 36 community health assistants, covering a much wider geography. Community health assistants work with patients to assess their home environment in order to better tailor care access. These health assistants report to a case management team which includes social workers as well as physicians, nurses, and pharmacists. The community health assistants take referrals from primary care physicians and case managers and also directly from community organizations, which can refer someone believed to have a social or health-related needs that could benefit from outreach and assistance. In doing so, they make it easier for clinical details to be focused on by case managers. • When the Massachusetts Department of Public Utilities held a hearing on revising regulation concerning utility shutoffs, attor- neys and health care team members from Boston Medical Center were able to successfully advocate for protection for high-risk patients during the winter season.8 This was achieved through the Boston Medical Center’s medical–legal partnership, a com- bined effort that involves attorneys, nurses, doctors, and other health team members. This partnership was able to offer on-site legal clinics within the medical center and screening that identi- fied high-risk patients (such as those with sickle cell disease and asthma) whose health would suffer from utility power cuts. The screening protocol was then combined with training programs for doctors, to ensure that the correct information for demonstrating medical need was included in protection letters for patients. This combined effort protected 193 people during the first year alone 7 For more information, see https://www.bettercareplaybook.org/_blog/2018/16/geis- inger-health-system-deploys-community-health-workers-address-social-determinants (ac- cessed on July 16, 2019). 8 For more information, see https://medical-legalpartnership.org/response/utilities-case- study (accessed on July 16, 2019. PREPUBLICATION COPY—Uncorrected Proofs

A WORKFORCE TO INTEGRATE SOCIAL CARE 77 and led to a joint testimony that resulted in the regulation itself being changed. FINDINGS • Effectively integrating social care into the delivery of health care requires effective interprofessional teams that include experts in social care. • The social care workforce can include many types of workers. Social workers are specialists in providing social care who have a long history of working within health care delivery. Models that include community health workers show promise. As mod- els continue to evolve and develop, roles may expand for other workers, such as social service navigators, aides, and assistants; trained volunteers; home health aides and personal care aides; and family caregivers. Other fields are emerging to meet the so- cial needs of older adults (for example, gerontology) and other specific populations. Integrating other professions—such as law- yers through medical–legal partnerships—also holds promise. • Understanding the role each member of an interprofessional team plays in the awareness, adjustment, assistance, alignment, and advocacy activities is important for ensuring effective collabora- tion among team members and for maximizing their ability to address patients’ social needs. • In order to effectively address social care in the delivery of health care, interprofessional team members should operate at their full scope of practice. Federal, state, and institutional barriers limit the scope of practice and the full use of social workers and other social care workers in caring for patients, such as in providing care management as part of an interprofessional team. • For interprofessional teams to effectively address social care in the context of health care financing structures need to be aligned. Federal, state, and institutional barriers exist that may limit the adequate payment of social workers, gerontologists, and other social care workers. • Research is needed on workforce issues related to integrating so- cial care and health care, including studying the effect on health and financial outcomes of various configurations of the health care workforce intended to better address the social needs of the population served. 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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