Serving the Underserved by Integrating with Community-Based Social Service Providers and Addressing Primary Prevention

Integrated and coordinated health care efforts often exclude strategies that address the social determinants of health and link the provision of direct services with population-level primary prevention activities. Since social determinants have a disproportionate negative impact on low income ethnic and racial populations, and primary prevention has the greatest potential for positive impact on the health of populations, leaving out these two components presents significant challenges to our ability to support the reduction of disparities in health status and the burden of disease for underserved populations.

 The California Institute for Behavioral Health Care Solutions sponsored a learning collaborative to support practice change efforts seeking to improve health outcomes for underserved populations by expanding integration activities to include partnerships between health centers, behavioral health providers, community-based social service providers, and culturally-specific navigators; as well as to incorporate strategies to link individual services to community level primary prevention. The 9 participating agencies from Sacramento, California, included ethnically-focused social service organizations who were often the primary agency providing services to people without a usual place of care.  Populations served included people without insurance and non-English speakers who were not already connected to a medical home.

 Participants were able to improve their capacity to meet the whole health needs of their clients and increase access to care. These findings suggest that community organizations that address the social determinants of health and engage in primary prevention are critical partners in health reform efforts that seek to address the needs of the unserved and underserved.