Background: Having limited individual and community resources increases the risk that older adults will become homebound,¹ which in turn contributes to poor health outcomes² and death.^2,3 Homebound adults also face disparities in healthcare access.⁴ Through improved care coordination, this collaboration aimed to address these disparities and promote health equity.

Program: Collaboration between a local health system, visiting nurse services, senior meals program, and university MPH program aimed to 1) identify barriers to effective coordination of health and social care for homebound adults, 2) create and implement a plan to address identified barriers, and 3) train students for cross-sector public health practice. Members met monthly, and students participated as volunteers, paid summer interns, and course enrollees.

Methods: Qualitative data included field observations (n=10), and interviews with frontline staff (n=12) and executives (n=8). Field reflections and transcripts were descriptively double-coded, themes identified, and findings co-interpreted using a 4-step process adapted from Binet and colleagues (2019).⁵ Students reflected on their experiences through written and oral feedback.

Results: Two themes were prioritized for short-term action 1) a lack of knowledge about other organizations and services hindered referrals, and 2) the referral process was inefficient. In response, students and staff developed ‘referral fact sheets’ for member organizations to learn about one another, and a common health information platform was selected for integration into existing systems. Data informed longer-term goals to improve patient/client health literacy and capability to use communications technology, and to enhance trust between patients/clients and staff. Twenty-two students (undergraduate, MPH, MHA) participated, with 27% engaging in more than one role. Students described how they developed a better understanding of the social determinants of health, and of the complexity of systems to address health and social needs. A few students described shifts in their education or career plans toward a focus on healthy equity.

Discussion: This pilot collaboration took steps to strengthen care coordination for homebound adults and informed the 2024 launch of a regional network of coordinated health and social care. In addition, the collaboration developed a new course in evidence-based cross-sector collaboration and inspired some students to pursue careers promoting health equity.