The following articles and case studies may be of interest to those who wish to learn more about social determinants of health and how health systems and health plans can improve outcomes by partnering with community-based organizations.

Addressing Social Determinants: Scaling Up Partnerships with Community-Based Organization Networks. Lance Robertson & Bruce Allen Chernof. Health Affairs. February 24, 2020.

As health care payment models become more value-based, health care systems are increasingly interested in approaches that address both medical needs and social determinants of health.

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Social Determinants as Public Goods: A New Approach to Financing Key Investments in Healthy Communities. Len M. Nichols & Lauren A. Taylor. Health Affairs. August 2018.

Good research evidence exists to suggest that social determinants of health, including access to housing, nutrition, and transportation, can influence health outcomes and health care use for vulnerable populations. Yet adequate, sustainable financing for interventions that improve social determinants of health has eluded most if not all US communities. This article argues that underinvestment in social determinants of health stems from the fact that such investments are in effect public goods, and thus benefits cannot be efficiently limited to those who pay for them—which makes it more difficult to capture return on investment. Drawing on lesser-known economic models and available data, we show how a properly governed, collaborative approach to financing could enable self-interested health stakeholders to earn a financial return on and sustain their social determinants investments.

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Caring, Cost-savings and Credibility in the Commonwealth. Aging Today. January-February 2018.

Medicare and Medicaid beneficiaries living in the Commonwealth of Virginia are receiving ex-traordinary (and convenient) care through a partnership model that has served thousands since its inception two years ago.
The VAAACares (Virginia Area Agencies on Aging—Caring for the Commonwealth) program provides comprehensive care coordination, care transitions and many other services to support the health and well-being of its enrollees. Maintaining an independent database for reporting per-formance measures, tracking care episodes and patient outcomes and other quality assurance measures, the program is a “one-stop-shop” for referrals, billing, reporting, data analytics, training and quality assurance.

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Collaborating to Reduce Hospital Readmissions for Older Adults with Complex Needs: Eastern Virginia Care Transitions Partnership. Case Study. Robert Wood Johnson Foundation. October 2017.

This case study features The Eastern Virginia Care Transitions Partnership (EVCTP), which includes more than 80 health care and social services organizations and is designed to reduce hospital readmissions and improve quality of care among older adults and those with complex illness through an evidence-based care transition model and in-home assessments.

This unique collaborative effort is a large-scale partnership including Bay Aging and four other Area Agencies on Aging, four health systems, three managed care organizations, and other health care and human service providers.

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