Clinical to Community Connections

Cross-Sector Partnerships to Address Social Determinants of Health

Social determinants of health are the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Public health’s focus on population-level interventions, disease prevention, and health metrics can provide leadership and expertise in addressing the social determinants of health, but public health cannot address social determinants of health alone. Factors such as housing, education, socioeconomic status, employment, and access to care can only be improved through collaboration with partners in other state, local, and federal agencies, and with private sector partners as well.

States and localities are already pioneering innovative ways to coordinate initiatives across agencies and with other community partners to create the conditions people need to live happy, healthy lives. These include financial incentives in Medicare and state Medicaid programs, supportive housing, and linkages with social services such as employment counseling. ASTHO has compiled a number of examples below that illustrate a selection of these efforts and public health’s role in them.

Behavioral Health Partnerships

ASTHO, in partnership with NACCHO and the Practical Playbook and with support from HRSA, conducted a nationwide environmental scan to investigate how healthcare delivery systems are partnering with community-based organizations on behavioral health issues. This resource includes a chart of state-by-state results (as of fall 2018) and a summary of early findings.

Community Health Needs Assessments

Community health needs assessments create an important opportunity to improve the health of communities. They ensure that hospitals have the information they need to provide community benefits that meet the needs of their communities. They also provide an opportunity to improve coordination of hospital community benefits with other efforts to improve community health. These resources detail opportunities for success, challenges, and state case examples. Access resources »

Cross-Sector Partnerships to Improve Health and Housing Outcomes

ASTHO, CDC, and the U.S. Department of Housing and Urban Development convened public, private, and nonprofit leaders to share their insights on how to improve health and housing outcomes. Individual participants described their work and experiences in cross-sector partnerships, mechanisms for funding and financing, as well as data sharing. The convening, which was held November 29-30, 2016, sought to improve understanding of the reasons why these approaches have been successful in the context of the communities where they were implemented. This document provides a summary of the information that was presented and shared at the convening as a resource for individuals and organizations.

Health Impact in Five Years (HI-5)

The Health Impact in Five Years (HI-5) Initiative is a tool developed by the CDC that highlights non-clinical, community-wide interventions that have demonstrated improved health within five years or less, as well as reported cost effectiveness and/or cost savings over the lifetime of the population of earlier. Strong cross-sector partnerships between public health agencies and other organizations are important to successfully implementing each of the fourteen highlighted evidence-based interventions. Featured resources include:

Health in All Policies

Health in All Policies (HiAP) can be defined as a collaborative approach that integrates and articulates health considerations into policy making and programming across sectors, and at all levels, to improve the health of all communities and people. HiAP requires public health practitioners to collaborate with other sectors to define and achieve mutually beneficial goals.

Featured resources:

Medicaid and Public Health Partnerships

ASTHO supports state health agencies by providing information and technical assistance to facilitate partnerships with Medicaid. These activities encompass a range of payment and delivery reform initiatives such as the State Innovation Models (SIM) Initiative and promoting collaborative opportunities between Medicaid and public health that will achieve the Triple Aim of better care, reducing costs, and improving population health outcomes. Access resources »

Social Determinants of Health: A Quick Reference Guide for State Offices of Rural Health and State and Territorial Health Officials

This quick reference guide, written in collaboration with the National Organizations of State Offices of Rural Health, outlines some of the major social determinants of health, which research shows has a large impact on health status. The document is aimed at familiarizing state offices of rural health and state and territorial health officials with the impacts of social determinants of health on rural populations. The guide outlines key interplays between health status and the social issues of housing, transportation, education, and food insecurity, and provides targeted resources and state examples to help public health officials learn more and take action on these significant drivers of health status, outcomes, and costs. Access resources »

Social Determinants of Health Learning Network

The Social Determinants of Health Learning Network is part of the nationwide Infant Mortality Collaborative Improvement and Innovation Network (CoIIN). Across the nation, 19 states in the learning network are aiming to build state and local capacity and test core strategies. The primary focus is innovation and spreading evidence-based policies and programs to improve social determinants of health and equity in birth outcomes. The learning network developed a consensus set of recommended strategies for reducing infant mortality by shifting the social determinants of health. Access recommended strategies »

Strengthening Community-Clinical Linkages to Improve Health Outcomes - Meeting Summary

The Association of State and Territorial Health Officials (ASTHO), funded by the Centers for Disease Control and Prevention (CDC), convened public, private, and nonprofit leaders in March 2019. These leaders shared examples with each other of collaborations between healthcare and community-based organizations that address health-related social needs. Convening attendees shared with one another specific strategies related to partnership-building, data-sharing, and sustainability, which ASTHO has referred to as the essential elements of effective community-clinical linkages. Access the resource »

Triple Aim: Strengthening the Capacity of Communities to Create Their Own Healthy Future

State health agencies have a unique opportunity to chart a new course as public health transitions from focusing solely on preventing disease to understanding the whole person and the impact culture, society, and the environment have on a person’s health journey. These resources aim to inspire state health agencies to build strong bridges with local and community organizations who support communities in strengthening their capacity to create their own health future. Access resources »

White Paper: Creating a Transformed Health System in the 21st Century

ASTHO envisions a health system of the 21st century that integrates public health, clinical care, social services, behavioral health, and other stakeholders to comprehensively address the root causes of poor health, ranging from lack of exercise, poor diet, lack of access to care, and other factors. Most determinants of our health affect us outside of doctors’ offices, which means the health sector in the future must work together closely to improve health and reduce costs. The white paper outlines ASTHO’s vision for an integrated health system in the future, and steps that can be taken today to achieve it.

Innovations in Financing

Public health agencies have historically relied on specific funding streams that focus on one disease condition, however innovative approaches in financing are needed to support cross-sector partnerships and interventions that address the social factors that impact health. Resources include an issue brief on blending and braiding funds, among others. Access resources »

Discussing How State Initiatives Can Build Healthier Communities

ASTHOExperts Blog: States’ Food, Housing, and Transportation Initiatives Aim to Reduce Health Disparities
This blog post discusses how access to food, housing, and transportation affects health and state initiatives to build healthier communities and increase equitable access to resources.