The Robert Wood Johnson Foundation believes that addressing complex, community-level barriers to good health requires fundamentally different ways of working across sectors.
This framework offers insights into what elements drive successful efforts to align the health care, public health, and social services sectors. A printable version of this framework is available in the Resource Library.
Sectors
The health care, public health, and social services sectors are working together in new ways that are accountable to the goals and needs of the communities they serve.
When sectors and systems work together to ensure everyone has the opportunity to be as healthy as possible, health disparities will decrease and health equity will improve.
“Strategically designing and connecting a community’s health improvement efforts across all major institutional players … offers great promise.” -ReThink Health
A town in Westchester County, New York, was the epicenter of the state’s earliest COVID-19 outbreak. The National Center for Complex Health and Social Needs describes how a new cross-sector coalition convened to address food insecurity caused by a rise in unemployment. Volunteers purchased meals from local restaurants and delivered them to families facing hunger. As the case study notes, “even as restrictions lift and individuals return to work, the coalition, informed by the unprecedented experiences that COVID-19 has brought, will continue its work and use its momentum to identify shared solutions to some of the most challenging issues in [the] community.”
What We’ve Learned
Publication
A Theory of Change for Aligning Health Care, Public Health, and Social Services in the Time of COVID-19
Brief
Aligning Health Care and Social Services: Recommendations for Effective Engagement
Publication
Doing Business Differently, Together: The Story of ReThink Health Ventures
Report
Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration
The health of an individual or community is affected by myriad factors—from housing and access to food to education and transportation—yet data systems are historically contained within a sector or even a single organization with little sharing. Successfully addressing complex challenges that affect community health such as maternal and infant mortality or the opioid epidemic requires having shared data and measurement systems to gather, organize, and share data between entities. This can effectively coordinate activities and use information to track shared progress towards equitable outcomes.
There is no one-size-fits-all approach for such a system, which can range from a hospital and social services organization incorporating social determinants of health data into an existing electronic health record to a community coming together to create an entirely new dashboard.
Aligning Systems for Health notes that data is inextricably linked to other elements of the framework. Data is a driver of collaboration steering nearly all aspects of aligning systems, particularly purpose and governance. Effective use of data, for instance, can ensure an equitable response to long-standing challenges.
Data Across Sectors for Health shares an example from Los Angeles County of a person experiencing homelessness who misses a health care appointment. Perhaps this absence isn’t noteworthy or could be attributed to lack of transportation or last-minute conflict. A shared data system, however, shows that this person spent the previous night in jail. Stepping back further, data reveal the client missed 10 prior mental health appointments. With a shared data system, the care team can determine the underlying complications faster and develop better solutions—all thanks to data sharing.
What We’ve Learned
Report
Aligning Systems with Communities to Advance Equity through Shared Measurement
Webinar
Building Trust for Cross-Sector Data Collaboration
Report
Unlocking the Value of Data Sharing: A Look Across Five Sectors
Webinar
Legal Considerations for Data Sharing
What We’ve Learned
Financing
“The actual structure still exists. The idea still exists. The question is, ‘How do we go on from here without continued funding?’” -Healthy Homes Des Moines
Aligning sectors strives to create partnerships that are “built to last.” Yet it is challenging to aim for sustainability or even keep the lights on when funding sources are unknown. While experts convened by Aligning Systems for Health caution there is a lack of collective knowledge and meaningful conversation about sustainable financing structures (which may be because such efforts are in early phases), many communities are effectively navigating this journey.
Sustainable financing includes appropriate incentives and shared accountability. It can be approached from three perspectives: sources, uses, and structures. Often there is a combination of public-sector funds like Medicaid waivers, philanthropic support (including grants), and community-based financing mechanisms like community wellness funds that can help bring in money to get aligning efforts off the ground.
For years the Oregon Health Authority and federal Medicaid funds have entirely financed the Yamhill Community Care Organization (YCCO) as a result of meeting care metrics outlined by the state. Aligning Systems for Health describes how YCCO’s board of directors makes the final payout determinations, but YCCO typically reinvests the funds back into the community through programs run by contracted partners that address social determinants of health, including housing, food insecurity, and education.
What We’ve Learned
Brief
Making Aligning Work: National Experts Reflect on Purpose, Data, Financing, and Governance
Publication
Interrupting Violence From Within the Trauma Unit and Well Beyond
Webinar
Closing Gaps in Health and Social Services for Low-Income Pregnant Woman
Publication
Bridging for Health: Improving Community Health Through Innovations in Financing
More Financing Resources
Governance
“Governance functions ensure accountability, transparency, and fairness across the various groups that are collaboratively stewarding transformative work in their region.” -ReThink Health
Good governance to guide efforts is necessary for successful cross-sector alignment, per research by the Center for Sharing Public Health Services and Public Health National Center for Innovations. This includes establishing and maintaining clear and appropriate roles, defined leadership and relationships, decision-making processes, data-sharing arrangements, and collaboration authority.
When aligning sectors, a backbone organization is often identified or newly formed to serve a leading role, such as the Atlanta Regional Collaborative for Health Improvement. Such an entity, as Aligning Systems for Health explains, can leverage existing infrastructure and resources while remaining impartial, propelling efforts forward effectively.
Early governance activities often include developing partnership agreements or memorandums of understanding, determining the role and appropriate representation of an advisory group or board, and agreeing on policies and procedures.
Aligning Systems for Health highlights how in King County, Washington, HealthierHere works across sectors to build an accessible and integrated services delivery system, with the ultimate goals of reducing health disparities, improving health outcomes and client experiences, and reducing per-capita costs. A leader of the organization credits its neutrality as a “secret ingredient” to its ability to work across sectors.
HealthierHere is governed by a 26-member cross-sector board in which the members represent their sector rather than organization, which encourages broad engagement and results in widely attended open board meetings. Board seats are divided equally among community members, social services agencies, and tribal partners; hospital systems, community health centers, and community behavioral health agencies; and government, payers, and philanthropy.
What We’ve Learned
Publication
Regional Transformation Efforts Conduct Governance and Management Activities Differently Than We Thought
Brief
Building Shared Outcomes with Community-Based Organizations
Case Study
Trenton Health Team: A Holistic Approach to Social Services
Webinar
Aligning Clinical and Public Health Systems for Population Health: Networks, Governance, and Incentives
More Governance Resources
Shared Purpose
“Aligned systems use a shared purpose to reach across the boundaries of their existing organizations to do something bigger together.” -Aligning Systems for Health
Efforts to align sectors are often initiated by external factors, according to Aligning Systems for Health, including overcoming a significant challenge (e.g., cost, efficiency, inequity), a philosophical or historical value (e.g., service to a vulnerable population), or an external or internal nudge (e.g., pandemic response, legislation, vision of a new leader, or sustainability concerns).
Yet without a mutual understanding and commitment to a vision and priority outcomes, aligning efforts will only get so far. As JSI finds, purpose is foundational to aligning sectors and requires significant time and resources. Once this is determined, meaningful work can begin.
Like in so many communities, organizations in Lake County, Colorado, previously conducted independent needs assessments and addressed the findings in siloed, disparate ways. Understanding the opportunity to combine forces, sector leaders convened and launched the Health and Happiness Project, which shapes community-wide priorities and guides how health care, public health, and social services can align efforts to achieve the greatest health for the most community members. At the heart of the planning process are the residents who voice their opinions in short online surveys and community meetings to determine which social, environmental, and economic factors to prioritize. Through this process, Lake County is tackling upstream determinants of health including affordable housing, a living wage, and child care.
What We’ve Learned
Brief
Making Aligning Work: National Experts Reflect on Purpose, Data, Financing, and Governance
Brief
Responding to COVID-19: An Activated Network with Health Collaboratives in Action
Case Study
Innovating Through Cross-Sector Alignment: Addressing Food Insecurity Through Economic Partnerships
Case Study
Combating Opioid Abuse Through a Unified State and Local Response: The Ohio Governor’s Cabinet Opiate Action
What We’ve Learned
Local Context
“Given variance in the local context, there is no single model or formula to align systems. However, there are commonalities that drive successful efforts.” -Aligning Systems for Health
Each community is unique in its specific strengths and challenges. What works for one community to align sectors may not work for another, given the dynamic nature of communities. These local factors play a critical role in if and how aligning is embraced by sectors, organizations, leaders, and community members.
Experts convened by Aligning Systems for Health note that external drivers often accelerate alignment activity, such as a health-related crisis (like the COVID-19 pandemic or opioid epidemic) or state or federal policy opportunities for aligning (such as the Accountable Health Community model or American Rescue Plan Act funding).
Likewise, internal capacity can enhance or inhibit aligning efforts. Having committed leadership, a workforce with appropriate skills, and strong backbone capabilities can set communities on a positive path forward. On the other end, constant turnover, lack of training, and conflicting priorities can hinder such work.
For many states the COVID-19 pandemic is driving new and existing collaboration between sectors and systems. Aligning Systems for Health describes how CARES Act funding enabled North Carolina to launch a community health worker initiative after years of planning. As part of this effort, more than 400 community health workers are being hired to immediately assist with COVID-19 contract tracing. In the long term these community health workers connect individuals with resources for health care, food, housing, employment, and other health and nonmedical needs.
What We’ve Learned
Brief
Making Aligning Work: National Experts Reflect on Context and Outcomes for Aligning
Case Study
Aligning in Action: Northwest Ohio Pathways HUB
Publication
Bridging for Health: Improving Community Health Through Innovations in Financing
Report
Addressing Healthcare’s Blindside in Albuquerque’s South Side
More Local Context Resources
Adaptive Factor: Community Voices
“We’ve had to abide by the values that we set up with those residents when we started. And their voice is the one that should take precedence.” -BUILD Health Challenge
When the community has a say, substantive change can happen. Elevating these voices ensures lasting improvements are driven by and for the community. This is particularly true for improving health locally as the health care, public health, and social services sectors are working together in new ways.
Active community engagement ensures its members are heard and integrated in the design process at the beginning of an effort and remain involved throughout. Taking these steps builds trust and addresses long-standing power dynamics that have silenced these voices in the past.
Experts note that having representatives from community-based organizations is not the same as having community members at the table, and community engagement is not synonymous with community leadership.
By elevating community voices, aligning efforts are leveraging county and tribal health councils to advance a Culture of Health in New Mexico (via Community Voices for Health), reducing obesity rates in Gastonia, North Carolina (via BUILD Health Challenge), and supporting youth in distressed Mississippi communities to succeed in school and beyond(via Aligning Systems for Health).
From its conception the Healthier Together initiative in Palm Beach County, Florida has empowered residents to be at the center of systems change, neighborhood by neighborhood. Aligning Systems for Health details how the resident-led approach intentionally incorporates community voices in setting priorities, sense-making around data, guiding grant funding decisions, and serving on the project steering committee, which is comprised of an equal proportion of lived leaders and learned experts.
What We’ve Learned
Webinar
Community Voices Panel: Shifting Power
Publication
Community Voice In Cross-Sector Alignment: Concepts and Strategies from a Scoping Review of the Health Collaboration Literature
Report
Community Approaches to System Change: A Compendium of Practices, Reflections, and Findings
Webinar
Bridging Trust and Community in Cross-Sector Alignment
More Community Voices Resources
Adaptive Factor: Equity
“Equity can be a process or an outcome, but in either case, it is widely understood to be critical for cross-sector aligning and, ultimately, for improving community well-being.” -Aligning Systems for Health
Addressing equity in the context of both health and race is a critical goal of aligning across sectors and, ultimately, critical for improving community well-being.
Health equity tailors support for each community so everyone who lives there has the same opportunity to live the healthiest possible life. Unlike equality, which provides everyone with the same resources, equity acknowledges that distinct communities and individuals face unique barriers and require assistance to achieve equal footing.
Centuries of racism and discrimination—including systemic, institutional, and individual barriers that deny equal opportunity to groups based on race or ethnicity—result in worse health outcomes, including shorter life expectancy for Black and brown individuals in the United States. Equity-driven initiatives work to correct systemic barriers and level the playing field.
Aligning Systems for Health highlights common barriers and strategies to improve equity, reduce structural racism, and ultimately diminish or eliminate persistent health disparities. Strategies at the individual, organizational, and systems level range from empowering social workers at the decision-making level to implementing Health in All Policies.
While equity is viewed as a “cross-cutting” principle influencing aligning, researchers funded by Aligning Systems for Health find that two primary issues arise when considering equity: a lack of clarity about its definition and uncertainty about operationalization.
Guided by Aligning Systems for Health, national experts outline how local context and interrelated factors play a role in aligned systems advancing health equity and addressing systemic racism:
Where trust is long-standing, people and organizations may begin honest conversations that serve as the impetus for lasting change.
Community engagement must be genuine—a seat at the table is not enough. A partnership with shared power is a must.
A strong, visible backbone organization is important to carry out this work.
Recognizing and respecting the experience of others is crucial. This mindset is central to participating in challenging conversations, reflecting deeply, and re-envisioning communities.
What We’ve Learned
Webinar
Moving from Talk to Action: Advancing Equity with Results Based Accountability
Report
Advancing Equity in the Nation’s COVID-19 Public Health Response and Recovery Efforts: Options for a New Administration
Brief
Listening Session Tackles Knowledge Sharing for Using Data Systems to Prioritize Equity in a Time of Crisis
Brief
Visualizing Health Equity: One Size Does Not Fit All Infographic
Aligning across sectors can be challenging because of inherent power imbalances between the sectors and between organizations and individuals. These differences in power can result from imbalances in resources, perceived value, historical practices, influence, or experience.
Research shows that the people with the least power are often most affected by the problem. This is particularly important because people are more likely to adopt change when they are involved in the process.
Power dynamics are at play in every interaction when aligning sectors, in ways visible (e.g., who is and is not represented on an advisory committee) and invisible (e.g., which sector brings the most money to the table). Successful efforts to align sectors must acknowledge power dynamics and work to level the field.
Minutes west of Charlotte, historical disinvestment in Gastonia, North Carolina resulted in mistrust and challenging conditions. To address upstream factors of health disparities like racism and inequitable food access, Healthier Highland convened sectors and partners to work together in new ways. The effort intentionally shifted power to the community by engaging resident-leaders, building a neighborhood association, strengthening local partnerships, and hiring a well-respected community member who understood the power dynamics in the community and broader context to lead the cross-sector effort.
What We’ve Learned
Webinar
Community Voices Panel: Shifting Power
Webinar
Power and Privilege in Cross-Sector Alignment
Brief
Making Aligning Work: Adaptive Factors
Case Study
Empowering Residents to Lead Their Peers in Improving Upward Mobility for Better Financial and Health Outcomes: Building Uplifted Families
More Power Dynamics Resources
Adaptive Factor: Trust
“Building trust means moving collectively from the Comfort Zone to the Learning Zone.” -Aligning Systems for Health
Trust, both with the community and between organizational partners,plays a foundational role in aligning sectors and must be built intentionally. Trust is critical to maintain connections, build community, and leverage success.
Two types of trust, relational and transactional, are necessary in collaborative efforts. Relational trust is earned through shared experiences and backgrounds, while transactional trust is earned through positive interactions. Trust may need to be rebuilt or regularly renewed.
Without trust other elements of aligning sectors are not possible. Research funded by Aligning Systems for Health is studying the role of trust and best practices for building and restoring it. JSI, for instance, notes the primary outcome of the collaborative formation stage should be increased trust, and this will grow and inform all other aspects of aligning.
Partners and community members alike may be cautious when sharing data, but foundational trust can ensure data are used in an effective and ethical way. Using real-world learnings from AllianceChicago, the Camden Coalition of Healthcare Providers (New Jersey), and the Providence Health and Services Center for Outcomes Research and Evaluation (Oregon), the National Centers for Complex Health and Social Needs highlights six strategies to achieve this, ranging from building on existing partnerships to understanding that building collaborative relationships takes time.
What We’ve Learned
Webinar
Bridging Trust and Community in Cross-Sector Alignment
Report
A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health
Webinar
Building Trust for Cross-Sector Data Collaboration
Brief
Making Aligning Work: Adaptive Factors
More Trust Resources
Outcomes
“The process of aligning across sectors may create pathways for different conversations, new perspectives, better listening, and a way to challenge the status quo.” -Aligning Systems for Health
When sectors work together in ways that are built to last, true change is possible. Achieving strong, lasting connections across systems helps build healthier and more equitable communities.
The sectors already have the expertise needed between them. Aligning sectors will improve how they work together to better support the people they serve and tackle complex, community-level barriers to good health, especially for people who find it hard to stay healthy, safe, and make ends meet.
To do so requires fundamentally reshaping policies, programs, and practices. Ultimately this will lead to a new paradigm that promotes health equity and reduces systemic racism, allowing every person in the United States to have a fair and just opportunity for health and well-being.
Process outcomes: Collaboratives break down the arc of work into important milestones that essentially set the stage for alignment.
Organization or system outcomes: These outcomes include capacity development and process-improvement activities that further strengthen the infrastructure necessary for enduring alignment.
Impact outcomes: Established initiatives have achieved measurable outcomes, including fewer sick days, decreased emergency department admissions, and increased supply of healthy housing stocks.
Why This Matters
Much like for Destiny and other new mothers in Arkansas, the Home Together program has been a lifeline for those in vulnerable communities, including underrepresented racial minority groups. A case study developed by Aligning Systems for Health shows how the program aligns the health care, public health, and social services systems to ensure that newborns leave the hospital for a safe, healthy, and stable home environment. Without it families may bounce between relatives’ houses or live on the street.
While there have been many process and project successes along the way, perhaps the most meaningful has been the effect on families. The first 78 mothers to receive six-month follow-up assessments showed an improvement in nearly every indicator measured, including housing status, mental health symptoms, and access to health care. As Destiny says, “This is just the beginning for me.”
What We’ve Learned
Brief
Making Aligning Work: National Experts Reflect on Context and Outcomes for Aligning
Case Study
Ensuring Healthy Outcomes for Louisville’s Vulnerable Children: Health Access Nurturing Development Services Program
Publication
To Improve Outcomes, Health Systems Invest in Affordable Housing
Case Study
Aligning Up Close: A Community’s Response to a Pandemic
