Partnering to Improve Community Health and Support Individuals with Complex Medical and Social Needs

Health care leaders and innovators are building collaborative teams that bring together clinical providers with community partners, such as social service and home care agencies, to meet patients’ functional, social and behavioral health needs.

Navigating partnerships between hospitals and health systems and community-based organizations can be challenging as these sectors may have different business and service models, client populations and financial structures.

Featured here are tools, assessments, evidence-based examples, and other resources developed by leading organizations across the U.S. to help build and sustain cross-sector partnerships that are working to improve the health of individuals and communities.

Download the compendium or access all resources from this page. Resources are organized in three main sections: Cross-Sector Partnering, Societal Factors and Population Health.

Bridging The Sectors: A Compendium of Resources | Partnering To Support Individuals With Complex Medical And Social Needs

Download a printable version of the compendium.

    • Integrating to Improve Health: Partnership Models between Community-Based and Health Care Organizations

      Nonprofit Finance Fund, 2018

      This resource outlines common partnership elements and establishes a framework to describe integration between community-based and health care organizations.

    • Building the Value Case for Complex Care

      Camden Coalition of Healthcare Providers and the National Center for Complex Health & Social Needs, 2021

      This toolkit is designed to help organizations gain the support of key stakeholders within the organization, as well as outside funders, partners and payers, in making the business or value case for complex care. Content includes how to adjust the value case in times of crisis and ways to champion efforts in various environments.

      Building Effective Health System-Community Partnerships: Lessons from the Field

      Center for Health Care Strategies, 2021

      This brief shares considerations for health care organizations and government entities working to build effective partnerships with the individuals and communities they serve and better address their health and social needs. It draws from the experiences of two sites: Hennepin Healthcare in Minneapolis and the Los Angeles Department of Health Services Whole-Person Care Program.

      WHO Community Engagement Framework for Quality, People-Centered and Resilient Health Services

      World Health Organization, 2017

      This report is the output of a three-day technical workshop to develop a community engagement framework for quality, people-centered and resilient health services and communities. The workshop was convened by WHO through a collaboration between the Health Promotion and Social Determinants Unit in the WHO Regional Office for Africa and the Service Delivery and Safety Department at WHO headquarters.

      Ensuring Access in Vulnerable Communities Community Conversations Toolkit

      American Hospital Association, 2017

      This toolkit provides ways in which hospitals and health systems can broadly engage their communities using community conversations events, social media and the community health assessment. It also outlines how to focus engagement on specific stakeholders, including patients, boards and clinicians.

      Community Engagement Toolkit for Rural Hospitals

      Washington State Hospital Association, 2014

      This toolkit is designed to help administrators leverage their hospital’s strengths and resources to engage in a community dialogue about health and form sustainable community partnerships. It includes an assessment to reflect on community engagement activities and determine what’s working well and what can be improved.

    • Lessons Learned from Partnerships Between Networks of Community-Based Organizations and Healthcare Organizations

      Nonprofit Finance Fund, 2021

      This report from the Advancing Resilience and Community Health (ARCH) initiative highlights themes and lessons learned that can inform new approaches to advancing community health. Through ARCH, Nonprofit Finance Fund partnered with three networks — EngageWell IPA, Metropolitan Alliance of Connected Communities, and Thomas Jefferson Area Coalition for the Homeless — to explore what it takes for CBO networks to come together around a shared vision for partnering with health care.

      The Partnership for Public Health

      American Hospital Association, 2020

      This webpage offers a suite of tools and resources that showcase leading strategies for active collaboration across the public health field. These resources were developed by engaging health care leaders across the U.S. as part of the Partnership for Public Health project, a joint effort between the Center for State, Tribal, Local and Territorial Support (CSTLTS) within the Centers for Disease Control and Prevention, American Hospital Association and the National Association of County and City Health Officials.

      Advancing Health Equity: PATH Addendum

      Nonprofit Finance Fund, 2020

      Effective partnership between community-based and health care organizations includes actively working to eliminate obstacles to health and ensuring that everyone has a fair and just opportunity to be as healthy as possible. This addendum to the Partnership Assessment Tool for Health (PATH) helps elevate the pivotal role that such partnerships play in contributing to equitable health outcomes in communities.

      Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration

      Public Health Leadership Forum and Health Care Transformation Task Force, 2018

      This report provides a framework to facilitate collaborative working relationships between the public health and health care sectors. The framework includes tactics and actionable strategies to support several elements of collaboration: governance structure, financing plan, cross-sector prevention models, data-sharing strategy, and performance measurement and evaluation.

      A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health

      American Hospital Association, 2017

      This playbook offers effective methods, tools and strategies for creating new partnerships and sustaining successful existing ones. The playbook incorporates lessons learned from the Learning in Collaborative Communities cohort, 10 communities across the U.S. with strong, successful hospital- community partnerships.

      Practical Playbook: Building a Partnership

      de Beaumont Foundation, Duke Family Medicine & Community Health and Centers for Disease Control and Prevention, 2017

      This resource provides a step-by-step process for organizing and preparing, planning and prioritizing, implementing, monitoring and evaluating, and sustaining a primary care and public health partnership project.

      Partnership Assessment Tool for Health

      Nonprofit Finance Fund, 2017

      Designed for community-based organizations and health care organizations already engaged in partnership, the Partnership Assessment Tool for Health, or PATH, provides a format to understand progress toward benchmarks characteristic of effective partnerships, identify areas for further development and guide strategic conversation. The tool is designed to help partnering organizations work together more effectively and maximize their impact.

    • Capturing Patient and Staff Experiences to Assess Complex Care Program Effectiveness

      Center for Health Care Strategies, 2022

      This brief shares insights from three Advancing Integrated Models pilot sites — Center for the Urban Child and Healthy Family at Boston Medical Center, Hill Country Community Clinic in California, and Denver Health — as part of a Robert Wood Johnson Foundation national initiative. These health care organizations tested a practical set of patient- and staff-reported measures to assess key aspects of complex care delivery.

      One-Stop Shop for Health Care and Community Partnerships

      HealthBegins, 2021

      This guide offers tools and vetted information on how to initiate, structure and fairly finance partnerships between health care organizations and community-based social service providers. Content is refreshed regularly.

      Readiness Assessment Tool

      Aging and Disability Business Institute, 2020

      This tool guides a community-based organization through the process of successfully preparing for, securing and maintaining partnerships with the health care sector, by assessing the organization’s current readiness and also providing a framework and resources for navigating the process successfully. (Must log in or create an account for free access to this tool.)

      Nonprofit Readiness for Health Partnership

      Nonprofit Finance Fund, 2018

      This tool assesses a community-based organization’s readiness to engage in partnership with health care organizations to deliver outcomes related to social determinants of health. It helps organizations review key capacities likely required for successful outcomes-oriented partnerships, to identify the organization’s strengths and weaknesses and to determine what capacity building and investment the organization may require before engaging in outcomes-oriented partnership arrangements. The tool is designed for self-assessment and internal use and not intended to evaluate potential partners.

      Hospital Guide to Reducing Medicaid Readmissions Toolbox

      Agency for Healthcare Research and Quality, 2017

      This package of tools accompanies the Hospital Guide to Reducing Medicaid Readmissions, which offers in-depth information about the unique factors driving Medicaid readmissions and a step-by step process for designing a locally relevant portfolio of strategies and collaborating with cross- setting partners to reduce Medicaid readmissions. Some of the tools are adaptations of best-practice approaches to make them more relevant to the Medicaid population; other tools are newly developed.

    • Community Health Assessment Toolkit

      American Hospital Association, 2017

      This toolkit offers a nine-step pathway for conducting a community health assessment and developing implementation strategies.

      Applying Research Principles to the Community Health Needs Assessment Process

      American Hospital Association, 2016

      This guide identifies tools and research principles to support community health needs assessments, describes patient- and community-centered practices to integrate into data collection during the CHNA process, and provides direction for identifying evidence-based resources to inform CHNA implementation strategies.

    • Geographic Data Sources for Assessing Health-Related Social Risk Factors

      Center for Health Care Strategies, 2020

      This resource summarizes publicly available data sources that can be used to further understand community-level, health-related social risk factors to better understand needs of potential high-risk populations. It was produced as part of a national initiative that brings together leading innovators in improving care for low-income individuals with complex medical and social needs.

      Population Health Toolkit

      National Rural Health Resource Center, 2019

      In cooperation with the Federal Office of Rural Health Policy, this toolkit provides visualizations of data from multiple sources that answer questions that rural hospitals and communities have about the health of their communities. Users can explore their data further by downloading the information to create their own analysis and graphs.

    • Patient and Family Advisory Councils Blueprint

      American Hospital Association, 2022

      This resource shares learnings and insights from a group of patient and family engagement leaders convened by the AHA. It offers guidance to help organizations build and maintain a high-performing patient and family advisory council, highlighting examples and key takeaways from the COVID-19 pandemic and linking to additional tools.

      Lessons on Consumer Engagement from Amplify

      Camden Coalition of Healthcare Providers, 2022

      This brief shares lessons of authentic consumer partnerships, highlighting opportunities to build trust, foster equity and inclusion, support community health and well-being, and improve health outcomes. It is designed to help organizations establish mutually beneficial partnerships with community members and individuals with lived experience.

      Change Package: Person-Centered Engagement at the Organizational Level

      Community Catalyst/Center for Consumer Engagement in Health Innovation, 2020

      This toolkit is for leaders and staff at organizations across the health care spectrum — hospitals, large medical practices, health clinics, health plans, accountable care organizations and more — to aid in developing meaningful person-centered engagement structures at the organizational level. It incorporates lessons from three case studies and includes tools and strategies for planning, implementing and scaling person-centered engagement structures.

      Screening for Social Needs: Guiding Care Teams to Engage Patients

      American Hospital Association, 2019

      This tool from the AHA’s Value Initiative is designed to help hospitals and health systems facilitate sensitive conversations with patients about nonmedical needs that may be a barrier to good health. It includes strategic considerations for implementing a screening program, tips for tailoring screenings to hospitals’ unique communities, case examples and a list of national organizations that can help connect patients with local resources.

      Better Care Playbook: Building Shared Outcomes with Community-Based Organizations

      Center for Health Care Strategies, 2019

      The “Playbook” series of resources was developed in partnership with the Camden Coalition of Healthcare Providers to share practical lessons and actionable guides in serving complex populations. This resource provides guidance to help health care organizations and community-based organizations build relationships that draw on each other’s strengths, put patients first and support ecosystem development in local communities.

      Engaging Patients and Community Members in Trauma-Informed Care Implementation Planning

      Center for Health Care Strategies, 2019

      This fact sheet outlines considerations to guide health care organizations in meaningfully engaging patients and community members in designing and implementing a trauma-informed approach to care.

      High-Need, High-Cost Patient Personas

      The Commonwealth Fund, 2019

      This toolkit includes a series of “personas” for different types of individuals with complex health and social needs, as well as their caregivers. The personas — which include people who are older than 65 with functional limitations, those who have an advancing illness, those who have three or more chronic conditions, and others — help depict the experiences, motivations and goals of a group of patients, as well as the barriers they face.

      Rural Community Health Toolkit

      Rural Health Information Hub, 2017

      This toolkit provides rural communities with the information, resources and materials needed to develop a community health program. Each of the toolkit’s six modules contains information that communities can apply to develop a rural health program, regardless of the specific health topic the program addresses.

  • Societal Factors that Influence Health: A Framework for Hospitals

    American Hospital Association, 2020

    This framework is designed to guide hospitals’ strategies to address the social needs of their patients, social determinants of health in their communities and the systemic causes that lead to health inequities. An overarching goal is for the entire field to have meaningful conversations around these issues.

    Pathways to Population Health: An Invitation to Health Care Change Agents

    American Hospital Association, Institute for Healthcare Improvement and project partners, 2019

    This guide brings together various Pathways to Population Health tools and resources in a practical and actionable way to help health care professionals and organizations accelerate progress toward the goals of population health, well-being and equity.

    Improving Population Health: A Guide for Critical Access Hospitals

    National Rural Health Resource Center, 2014

    This tool provides guidance for rural hospital leaders to incorporate population health principles and programs into strategic planning and operations. A systems-based framework is used to identify critical success factors for successfully managing this transition. Tools, resources, suggested readings, case studies and additional materials on how to integrate population health as culture change also are included.


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This content was developed by the American Hospital Association with support from the Robert Wood Johnson Foundation and content assistance from the National Center for Complex Health and Social Needs, an initiative of the Camden Coalition of Healthcare Providers. Resources are updated frequently to keep content current.

Inclusion in this compendium does not necessarily imply endorsement by the AHA, nor should it be construed as advice from the AHA. Rather, these tools and resources are meant to assist hospitals and health systems and their community partners in developing effective partnership strategies.