Integrating Health and Social Services in the U.S.: A Systematic Review

Background and purpose: Integration of physical health, behavioral health and social services is a principal aim of the Affordable Care Act (ACA), as it has the potential to expand service access, improve quality, and decrease health care costs by reducing need for acute medical services. The ACA promotes integration through a number of new initiatives, including accountable care organizations and patient-centered medical homes, that encourage physical and behavioral health service providers to coordinate and ideally, co-locate services. However, little is known about the current availability of integrated of health and social services in the United States, or the service integration strategies that characterize them. In response, the current systematic review summarizes and codifies interventions, published between 2010 and 2017, that address both social and medical needs in the United States. The outcomes of interest include impact on physical health, behavioral health and cost.

Methods: A systematic review examined randomized controlled trials (RCTs) of interventions of routine care versus integrated health and social care published between 2010 and 2017. Outcomes of physical health, behavioral health and cost were evaluated. The initial search of three scholarly journal databases (PubMed, PsycInfo and Social Service Abstracts yielded 300 articles eligible for full text review. Search terms included intervention, randomized controlled trial and set of terms related to social determinants of health. Of these, 77 met final eligibility criteria.

Results: After full text review of 300 articles, 77 articles (26%) met our eligibility criteria: 1) inclusion or a social intervention or a health intervention that aimed to address a social determinant of health; 2) a documented, health, behavioral health or cost outcome; 3) the study took place in the United States between 2010 and 2017 and focused on adults; 4) the study was an original, complete randomized controlled trial. Reviews of randomized controlled trial studies showed the top three categories of social intervention were psychoeducation (49%), therapy/counseling (23%), and group therapy (18%). Of medical conditions, the most studied disease by far was HIV/AIDS (34%), followed by Diabetes (12%). Of the studies examined, 27% had a technology component involved.

Conclusions and implications: This systematic review indicates studies evaluating the integration of health and social care randomized controlled trials are limited, despite evidence demonstrating (a) that nonmedical factors --including social, behavioral and environmental determinants of health -- consistently play a substantially great role than medical factors, and (b) better health outcomes when co-occurring health and social problems are treated in tandem. Results identify specific integrated service intervention options that simultaneously address health and social needs and have a positive impact on health, behavioral health and costs. The results highlight the need to identify and develop integrated service models with the positive impacts on health, behavioral health and costs.