| Summary: | <p class="MsoNormal" style="margin: 0pt;"><span style="font-size: small;"><span style="font-family: Times New Roman;"><strong>Introduction and Background</strong><span style="mso-bidi-font-weight: bold;">:</span> Few financial incentives in the United States encourage coordination across the health and social care systems. Supportive Service Programs (SSPs), operating in Naturally Occurring Retirement Communities (NORCs), attempt to increase access to care and enhance care quality for aging residents.<span style="mso-spacerun: yes;"> </span><span style="mso-bidi-font-size: 11.5pt;">This article presents findings from an evaluation conducted from 2004 to 2006 looking at the feasibility, quality and outcomes of linking health and social services through innovative NORC-SSP and health organization micro-collaborations. </span></span></span></p><p class="MsoNormal" style="margin: 0pt;"><span style="mso-bidi-font-weight: bold;"><span style="font-size: small; font-family: Times New Roman;"> </span></span></p><p class="MsoNormal" style="margin: 0pt;"><span style="font-size: small;"><span style="font-family: Times New Roman;"><strong>Methods</strong><span style="mso-bidi-font-weight: bold;">:</span> Four NORC-SSPs participated in the study by finding a health care organization or community-based physicians to collaborate with on addressing health conditions that could benefit from a biopsychosocial approach. Each site focused on a specific population, addressed a specific condition or problem, and created different linkages to address the target problem.<span style="mso-spacerun: yes;"> </span>Using a case study approach, incorporating both qualitative and quantitative methods, this evaluation sought to answer the following two primary questions: 1) Have the participating sites created viable linkages between their organizations that did not exist prior to the study; and, 2) To what extent have the linkages resulted in improvements in clinical and other health and social outcomes?<span style="mso-spacerun: yes;"> </span></span></span></p><p class="MsoFooter" style="margin: 0pt; tab-stops: 36.0pt;"><span style="mso-bidi-font-weight: bold;"><span style="font-size: small; font-family: Times New Roman;"> </span></span></p><p class="MsoFooter" style="margin: 0pt; tab-stops: 36.0pt;"><span style="font-size: small;"><span style="font-family: Times New Roman;"><strong>Results:</strong> Findings suggest that immediate outcomes were widely achieved across sites: knowledge of other sector providers’ capabilities and services increased; communication across providers increased; identification of target population increased; and, awareness of risks, symptoms and health seeking behaviors among clients/patients increased.<span style="mso-spacerun: yes;"> </span>Furthermore, intermediate outcomes were also widely achieved: shared care planning increased across providers; continuity of care was enhanced; disease management improved; and self care among clients improved.<span style="mso-spacerun: yes;"> </span>Finally, several linkage partnerships were also able to demonstrate improvements in distal outcomes: falls risk decreased; clinical indicators for diabetes management improved; and inappropriate hospitalizations decreased.</span></span></p><p class="MsoNormal" style="margin: 0pt;"><span style="font-size: small; font-family: Times New Roman;"> </span></p><p class="MsoNormal" style="margin: 0pt;"><span style="font-size: small;"><span style="font-family: Times New Roman;"><strong>Discussion:</strong> Using simple, familiar and relatively low-tech approaches to sharing critical patient information among collaborating organizations, inter-sector linkages were successfully established at all four sites.<span style="mso-spacerun: yes;"> </span>Seven critical success factors emerged that increase the likelihood that linkages will be implemented, effective and sustained: 1) careful goal selection; 2) meaningful collaboration; 3) appropriate role for patients/clients; 4) realistic interventions; 5) realistic expectations for implementation environment; 6) continuous focus on outcomes; and, 7) stable leadership. Focused, micro-level collaborations have the potential to improve care, increasing the chance that organizations will undertake such endeavors.</span></span></p>
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