Integrating Medical Care and Social Services Can Improve Care Quality for Elders

By Terry Fulmer and Nora OBrien-Suric

The world of healthcare is slowly acknowledging what community-based social service workers have known for decades—health happens at home. Helping to maintain and sustain older adults’ highest possible level of functioning and the best quality of life has been the undertaking of community-based services. Yet, the medical world has little knowledge of the array of services that can and should be provided, which would not only complement medical care, but could help to improve it.

A 2011 Robert Wood Johnson Foundation survey (Health Care’s Blind Side: The Overlooked Connection Between Social Needs and Good Health) of 1,000 primary care physicians revealed that 86 percent felt “unmet social needs are leading directly to worse health” across all socioeconomic groups, and that it is as important to address these factors as it is to address patients’ medical conditions.

Healthcare System Must Address Social Service Needs

To meet older adults’ health needs and support their well-being, the healthcare system, which encompasses hospitals and health plans, must address the critical social service needs that will ensure better health outcomes, including the need for adequate nutrition; transportation to medical appointments, the pharmacy and the grocery store; assistance with medications; personal care in the home; and caregiver support. To foster this integration in the new and fast-changing healthcare landscape, social service agencies must create business partnerships with the healthcare system to identify and integrate social services.

Seizing this dramatic opportunity for system redesign will require new business relationships between the social service and healthcare sectors. Both must be readied for this change. The healthcare sector will benefit from knowing the value of social services to their patients’ health and to the health system’s bottom line. The social service sector, including area agencies on aging and other local aging and disability organizations, must be prepared to demonstrate that they can deliver the quality, volume, confidentiality, geographic coverage, data and reporting needs of the healthcare system.

The mission of The John A. Hartford Foundation is to improve care for older people. For more than 30 years, the Foundation has provided funding to increase the number of healthcare professionals trained in geriatrics, as well as to develop models of care for older adults.

One thing we have learned is that older adults need a combination of expert geriatric medical care and skilled supportive social services to be healthy and independent for as long as possible. Three years ago we developed a new strategic focus that seeks to break down the silos in healthcare and meet the needs of older people through comprehensive, continuous, coordinated and age-expert care. We funded a project that helps support a national movement to do just that—integrate medical care and social services to improve the health of older people.

Historically, the medical community and the social services network have not connected in any formal way. Now, both entities are seeking to partner to realize better health outcomes for older people, while maintaining a sustainable service delivery model.

To help make these integrated networks successful, social service agencies need help building organizational capacity to deliver high-quality services, bring them to scale and participate in new, complex financial arrangements. The John A. Hartford Foundation provided support for the development of two integrated medical and social networks.

The Partners in Care Foundation developed one prototype in Southern California, and a collaborative co-led by Elder Services of the Merrimack Valley and Hebrew SeniorLife developed the second prototype statewide with a contracting hub for six regional networks as the delivery system. Also, funding was provided to convene the other 18 network sites receiving technical assistance from the Administration for Community Living (ACL).

The results of the three-year grant include proving the viability of the prototype social service agency networks; building the business capacity of the networks; and developing partnerships with healthcare systems that bring high-value, evidence-based programs and services to older patients outside the hospital setting (for more information, see Evidence-Based Medicine and the Changing Nature of Health Care: Meeting Summary, IOM Roundtable on Evidence-Based Medicine; Washington, D.C.: The National Academies Press, 2008). The initiative’s next phase is intended to communicate and disseminate the lessons learned and tools developed.

New National Initiative Links Medical Care with Social Services

With funding from The John A. Hartford and The SCAN foundations, the ACL will lead this effort and continue to partner with the National Association of Area Agencies on Aging, in collaboration with ASA and the Independent Living Research Utilization/National Center for Aging and Disability. Each of these partners will work together to improve the care of older adults and people with disabilities through the creation of a national initiative linking medical care with social services extensive network.

This initiative will:

Build a national resource center to serve as the go-to place for social service agencies interested in acquiring skills for sustainability and business planning.

Develop an assessment tool for determining the capacity for and a gap analysis of social service agencies to contract with hospitals and other healthcare entities.

Provide training and technical assistance to enhance the business capacity of social service agencies and their partner networks, positioning them to negotiate, secure and successfully implement contracts with healthcare entities (hospitals and health plans).

Conduct an outreach and educational campaign targeting the healthcare sector, including hospitals and health plans, to provide critical information on the return on investment in contracting with social services, to address the social determinants of their patients’ health and their cost-savings.

Develop a sustainability strategy, building on the momentum to increase financial support for this national initiative that will establish a new norm of business partnerships and contracts between social service agencies, healthcare systems and health plans.

We invite Aging Today readers to participate in this national initiative. There are many opportunities to learn about, engage in and be a part of this transformational culture change that will improve care for older adults. For more information go to Together, we will improve care of older adults by using integrated networks of medical care and social services.

Terry Fulmer, Ph.D., R.N., F.A.A.N., is president of The John A. Hartford Foundation in New York City. Nora OBrien-Suric, Ph.D., is a senior program officer at the Foundation.

Editor’s Note: This article appears in the May/June 2016 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store or Join ASA.

" target="_blank">Aging and Disability Business Institute logo

The SCAN Foundation, The John A. Hartford Foundation, the Administration for Community Living, the Gary and Mary West Foundation, the Marin Community Foundation, and the Colorado Health Foundation have united to fund a three-year grant to develop and establish the Aging and Disability Business Institute, housed within n4a. Under the grant, ASA and n4a are collaborating on a series of articles in Aging Today that will help to prepare, educate and support community-based organizations and health care payers to provide quality care and services.

Submitted by Anonymous (not verified) on Thu, 2016-07-28 07:54


I must appreciate the time taken to write such an insightful article. I truly agree with this article. It is well known that United States spend more on healthcare than any other nation in the world yet with no good health outcomes. An improved coordination between medical care and social service can surely improve the health outcomes and also lower the cost of healthcare services.