Funder: Robert Wood Johnson Foundation and Kaiser Permanente Community Health


Health care and community-based organizations (CBOs) across the country are increasingly working together to address social needs that may be contributing to poor health outcomes. These cross-sector relationships are occurring under a variety of partnership models, yet little is known about the factors that contribute to their success.

The following case studies illustrate the potential for diverse and effective models between CBOs and health care organizations. They provide important lessons for how successful partnerships deliver services, share information, secure funding, engage their communities, and evaluate success:

Project Access NOW’s C3 Community Assistance Program: Ensuring Safe Discharge from the Hospital – Looks at a partnership including Project Access NOW, six area hospital systems and two coordinated care organizations that is connecting individuals in Portland, Oregon to social services to ensure safe discharge from emergency and inpatient hospital settings. (August 2018)


Hunger Free Colorado: Connecting Vulnerable Patients to Food and Nutrition Resources – Examines a collaboration involving Hunger Free Colorado, Kaiser Permanente, Children’s Hospital Colorado, and Denver Health that is facilitating screening for food insecurity and connecting at-risk patients to needed food and nutrition services. (August 2018)


2-1-1 San Diego: Connecting Partners through the Community Information Exchange – Explores how 2-1-1 San Diego is working with social service and health care providers to improve care coordination through an online platform that enables participating providers to better understand a client’s interactions with health and community services. (August 2018)


Ensuring Healthy Outcomes for Louisville’s Vulnerable Children: Health Access Nurturing Development Services Program – Looks at a partnership between Family & Children’s Place and the Louisville Metro Department of Public Health and Wellness that provides home visitation services for new and expectant parents to equip them with the skills to support a healthy family. (October 2017)


Housing is a Health Intervention: Transitional Respite Care Program in Spokane – Explores a collaboration among Catholic Charities Spokane, Providence Sacred Heart Medical Center (part of the Providence Health & Services health system), and Volunteers of America that provides post-hospitalization care and tailored, coordinated services to homeless clients to give them a better chance at healing. (October 2017)


Collaborating to Reduce Hospital Readmissions for Older Adults with Complex Needs: Eastern Virginia Care Transitions Partnership – Features a collaborative in Virginia including more than 80 health care and social services organizations, which is designed to reduce hospital readmissions and improve quality of care by using evidence-based care transition coaching and in-home assessments. (October 2017)


Meeting the Health and Social Service Needs of High-Risk LGBTQ Youth in Detroit: The Ruth Ellis Health & Wellness Center – Looks at a partnership between the Ruth Ellis Center and the Henry Ford Health System, an integrated health care organization, which aims to improve the long-term health outcomes for one of the region’s most vulnerable populations. (October 2017)