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Experts estimate that up to 80 percent of a person’s health is determined by nonclinical factors—things like financial stability, access to safe, affordable housing and to healthy food, and social supports. Yet, as a society, we spend billions of dollars providing clinical care that often fails to effectively address the social, economic, and environmental factors that impact health.

Community-based services—rather than clinical services—offer support around these broader health determinants and often become particularly important as people age. Services such as transportation, meal preparation, socialization programs, housekeeping, and counseling on financial benefits can support older adults in maintaining their independence, managing chronic health conditions, and preserving their quality of life.

Ongoing federal and state health reform initiatives—including Accountable Health Communities, State Innovation Models, and New York State’s Delivery System Reform Incentive Payment (DSRIP) Program—aim to improve the integration of social services and medical care and reduce reliance on hospital-based services. Despite significant investments, these large-scale initiatives have not resulted in a reliable and straightforward method of breaking down silos and aligning existing systems.

CCC: A Promising Approach
The Robert Wood Johnson Foundation funded the Systems for Action research program to “test new ways of connecting the nation’s fragmented medical, social, and public health systems.” A Systems for Action grant enabled researchers at New York University (NYU) and the New York Academy of Medicine (NYAM) to investigate the impact of Community Care Connections (CCC), a program developed and implemented by Lifespan of Greater Rochester, a community-based aging services provider located in Rochester, New York, which aims to integrate social services into medical systems of care to meet the triple aim of improved patient experience, better patient health, and lower health care costs.

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