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A collaboration team to build social service partnerships within a safety-net health system



To facilitate safety-net healthcare system partnerships with community social service providers, the Los Angeles County Department of Health Services (LAC DHS) created a new collaboration team to spur cross-agency social and medical referral networks and engage communities affected by health disparities as part of a Sect. 1115 Medicaid waiver in Los Angeles County entitled Whole Person Care-Los Angeles (WPC-LA).


This observational research reviews three years of collaboration team implementation (2018–2020) through Medicaid-reportable engagement reports, a collaboration team qualitative survey on challenges, facilitators, and recommendations for community engagement. Member reflections for survey findings were conducted with the collaboration team and LAC DHS WPC-LA leadership.


Collaboration team Medicaid engagement reports (n = 144) reported > 2,700 events, reaching > 70,000 individuals through cross-agency and community-partnered meetings. The collaboration team survey (n = 9) and member reflection sessions portrayed engagement processes through outreach, service assessments, and facilitation of service partnerships. The collaboration team facilitated community engagement processes through countywide workgroups on justice-system diversion and African American infant and maternal health. Recommendations for future safety net health system engagement processes included assessing health system readiness for community engagement and identifying strategies to build mutually beneficial social service partnerships.


A dedicated collaboration team allowed for bi-directional knowledge exchange between county services, populations with lived experience, and social services, identifying service gaps and recommendations. Engagement with communities affected by health disparities resulted in health system policy recommendations and changes.

Peer Review reports


California and other states with expanded Medicaid coverage are re-envisioning health and social service partnerships to address unmet social needs and reduce health disparities and costly acute healthcare utilization [1,2,3,4]. Improving health equity requires social care coordination between health systems, social service agencies, and community resources addressing the social determinants of health [5,6,7]. Policy shifts integrating social care coordination into healthcare delivery have helped initiate community partnerships or community stakeholder committees, facilitated service coordination, developed interventions for quality of care, and provided insight into local needs, resources, and strategies for culturally congruent care [8, 9]. In recent years, Sect. 1115 Medicaid waivers funded initiatives coordinating social care into healthcare delivery, including building or strengthening infrastructure for community partnerships for social needs services [10]. In California, 25 programs in 26 counties implemented the Medicaid (called Medi-Cal in California) 1115(a) waiver “Whole Person Care” (WPC) pilot to integrate the social and medical needs of high-risk, high-utilizing Medi-Cal beneficiaries [10]. Medi-Cal WPC Pilots were required to improve care coordination, access to care, and integrate services among “local entities that serve the target population” [11]. The limited statewide funding waiver was funded from 1/1/2016–12/31/2020 but was extended through December 2021, and lessons learned have since been incorporated within California Advancing and Innovating Medi-Cal (CalAIM) which leverages Medicaid to achieve a socially integrated health delivery system, promoting health equity by addressing the complex clinical and social needs facing patients with high utilization of acute care services [12].

The Los Angeles County Department of Health Services (LAC DHS) Medicaid WPC pilot was entitled Whole Person Care-Los Angeles (WPC-LA). WPC-LA aimed to deliver coordinated services to the most vulnerable Medicaid beneficiaries [10, 13]. WPC-LA integrated health, behavioral health, and social service systems through a community health worker (CHW) model [14] for six high-risk populations experiencing homelessness, justice involvement, barriers to a healthy pregnancy, mental health disorders, substance use disorder, and complex health conditions [13]. While LAC DHS is the primary administrator of WPC-LA, the Los Angeles County (LAC) Departments of Public Health (LAC DPH), Mental Health (LAC DMH), Public Social Services (DPSS), and Justice Departments (Sheriff’s office, Office of Diversion and Reentry, Probation, etc.) are key county stakeholders in addition to health plans, clinics, and community-based organizations (CBOs). CHWs, social workers, case managers, and other direct service professionals promoted health and social care continuity, connecting WPC-LA patients to primary care, specialty care, and social services, including housing, substance use treatment, reentry services, employment, food, and legal advocacy.

To support coordinating social services in healthcare delivery, WPC-LA developed a new collaboration team in the LAC DHS health system for community engagement, partnership, and cross-agency collaboration to support the six populations' tailored health and social needs. The goals of the team included: (a) initiate and foster purposeful engagement to increase awareness of WPC-LA program offerings and expand the social service referral network; (b) identify critical assets and gaps within the county’s health and social services with a focus on reducing health disparities; (c) build community capacity to promote health equity through collaborations addressing social determinants of health for WPC-LA populations, and (d) create lasting pathways for diverse community voices in the decision-making process through community action teams and workgroups dedicated to problem-solving within health inequities. Herein is a descriptive study that describes the roles of this novel health-system-embedded collaboration team and challenges, facilitators, case studies, and recommendations for health-system community engagement processes for addressing health disparities, service gaps, and social needs.


UCLA researchers partnered with the LAC DHS collaboration team to conduct narrative and observational research documenting lessons learned and recommendations for creating safety-net health system collaboration with local communities on social service partnerships and health disparities. This study was found to be exempt by the UCLA Institutional Review Board. We report our findings using the Standards for Reporting Qualitative Research [15, 16].

Setting and role of the collaboration team

Collaboration team members (n = 9) were new LAC DHS hires between 9/2017 and 3/2018. Recruitment focused on individuals with experience in nonprofits, social services, and grassroots community organizing and lived experience or shared adversity related to the six WPC-LA focus populations. Collaboration team members were full-time LAC DHS employees who directly reported to WPC-LA leadership. As a health system representative, each collaboration team member worked across eight Los Angeles County geographic regions called Service Planning Areas (SPAs). The role facilitated regional service delivery, efficiency, and collaboration across the WPC-LA structure (from CHWs to WPC-LA leadership), government agencies providing public health, social services, mental health, and justice care (including LAC DPH, DMH, DPSS, and City or County Justice Systems), and CBOs providing social services (homeless shelters, substance use treatment, legal aid, etc.). The structural organization of the collaboration team within LAC DHS’s WPC-LA leaders, government agencies, and community entities is depicted in Fig. 1. Herein, the term collaboration within “collaboration team” refers to the three components described by Berkowitz [17], relating to the collective effort, a social change process, and information exchange for mutual benefit.

Fig. 1
figure 1

LAC-DHS Whole Person Care-Los Angeles staff structure* *This figure focuses specifically on highlighting the Collaboration Team’s structure within the health system and does not comprehensively display levels of interaction between the other roles, positions, or agencies. For instance, CHWs conducted referrals to CBOs, whereas the Collaboration Team conducted outreach and partnership on agency-wide levels

Data collection and analysis

Following three years of collaboration team implementation within WPC-LA (9/2017–12/2020), UCLA researchers used the CDC’s six-step framework process for organizing program evaluation [18] to: a) compile and analyze LAC DHS reports on the collaboration team’s collaboration activities for Medi-Cal reporting, b) conduct a qualitative LAC DHS collaboration team survey on challenges, facilitators, and recommendations for the health-system community engagement, and c) hold member reflection meetings to refine survey findings with the collaboration team and LAC-DHS WPC-LA leadership.

  1. a)

    Medi-Cal Collaboration reports. LAC DHS monthly and annual engagement activity reports were compiled from 1/2018–12/2019, encompassing the number of events, attendees, and event focus population (homelessness, justice involvement, barriers to a healthy pregnancy, mental health disorders, substance use disorder, and complex health conditions, or other). These reports were generated quarterly by LAC DHS and sent to the State of California Health and Human Services Agency to determine stakeholder engagement and outreach, Medi-Cal resource use, and receive Medi-Cal incentives, per Medi-Cal waiver requirements for improving the integration of care coordination among county agencies and appropriate care services [11]. Engagement events included meetings with non-LAC-DHS collaborators working on service integration and collaboration, including community members, CBOs, or county agency stakeholders, i.e., DMH or DPSS. Reports following the onset of the COVID-19 pandemic in March 2020 were not counted herein as collaboration team efforts shifted to meet pandemic needs. Collaboration outcome reports are tallied herein to exemplify cross-sector collaboration connections conducted by the collaboration team.

  2. b)

    Collaboration Team survey. A survey was distributed to the nine original collaboration team members in February and March 2020 and solicited demographic and open-ended questions on successes, challenges, facilitators, and recommendations for other safety net systems for community engagement processes. See Table 1 for survey questions. Qualitative results from the Collaboration Team survey were analyzed using reflexive thematic analysis by an experienced qualitative researcher [SC] unaffiliated with LAC DHS and research findings [19, 20].

  3. c)

    Member reflections. Following analysis, we reported and reviewed preliminary themes in eleven subsequent 1–2 h meetings with the Collaboration Team (n = 7 meetings, 9 Collaboration Team members) and LAC-DHS leadership (n = 4 meetings with three individuals). The meetings aimed to obtain member reflections on preliminary qualitative analysis, where participants are invited to provide further insight and understanding of findings [21, 22]. These member reflection meetings included presenting a subset of preliminary themes from the survey, inviting participants to provide descriptive examples of case studies representing the themes, or providing comments, reflections, or suggested edits for the preliminary results. Meeting notes were utilized to validate, refine, and expand themes. These sessions allowed for probing how collaboration team outreach, partnerships, and service assessments were conducted and obtaining recommendations for future social service and safety-net collaboration.

Table 1 Collaboration team survey questions


Demographic characteristics of the collaboration team

The nine WPC-LA collaboration team members active at the time of this evaluation were all women, identifying as Black/African American (3), biracial (2), Latina (2; one of Central American descent, and another of Mexican/Chicana descent, both identified as Indigenous), White (1), and Asian American (1). Types of lived experience collaboration team members portrayed reflected WPC-LA focus populations, including personal or familial experience with incarceration, substance use, barriers to reproductive healthcare, mental health, complex health conditions, homelessness, racism, and use of public benefits.

Medi-Cal collaboration reports

From the LAC-DHS Medi-Cal collaboration reports (n = 144), we identified over 2,700 in-person collaboration events reaching over 70,000 people from January 2018 to March 2020 to increase awareness of WPC-LA programs and expand the social service referral network. Outreach ranged from 10 to 60 meetings per month per Collaboration Team member. A description of outreach activities is described next.

Survey and member reflection results

The survey results (n = 9 respondents) and Collaboration Team and LAC DHS leadership member reflections (n = 11 meetings with 9 Collaboration Team members and three LAC DHS health system leadership individuals) describe the collaboration team's evolutionary, phased role in outreach, service assessments, and building engagement processes, (see Fig. 2), assets and challenges faced during implementation, and recommendations and lessons learned for other safety net systems.

Fig. 2
figure 2

Collaboration team community engagement processes

Phase 1: collaboration team outreach: initiating health system relationships with local community social service organizations

The collaboration team worked in specified Los Angeles SPAs to conduct outreach meetings with local direct-service CBOs and county agencies, including DPSS, LAC DMH, and LAC DPH, on services related to WPC-LA focus populations. The purpose was to (1) increase local knowledge of WPC-LA program offerings for LAC DHS referral, (2) build a bilateral social service referral network for CBOs, county agencies, and LAC DHS WPC-LA staff, such as CHWs or case managers, and (3) initiate bi-directional discussions on service gaps or assets for the WPC-LA focus populations. Outreach focused on social services serving LAC-DHS focus populations, such as regional LAC DMH health neighborhood groups, local homeless coalitions or agencies, legal aid organizations, health services, reentry services, and maternal health advocacy groups. Outreach continued using snowball sampling and referrals from the county or community contacts. Outreach meetings included a general WPC-LA overview, WPC-LA program services and eligibility for the six WPC-LA focus populations, referral information, and discussion of any congruent services or service gaps. Meetings would attempt to reach multiple staff levels within CBOs (CHWs to CBO directors). The in-person outreach supported knowledge sharing of available services and care coordination processes, built relationships with local agencies and community stakeholders, and provided direct bilateral contacts at each entity. As a collaboration team member explains,

Collaboration is a process and an outcome. As a process, it takes building authentic and supportive relationships with individuals and organizations. As an outcome, it creates strong partnerships and programs. Community engagement in our role is also about building genuine, supportive, mutually beneficial relationships."

The team collected public-facing information on CBO services from outreach meetings, including services, hours, and eligibility. Information was added to OneDegree (, an online referral platform for local social, health, and other services (i.e., employment, public benefits, and food pantries). WPC-LA collaboration team members and CHWs added over 1,000 CBOs from 2019 to 2020 and created multiple specialty social and medical resource websites tailored for WPC-LA population-specific needs (i.e., reentry, housing, reproductive health) on OneDegree.

Phase 2: collaboration team service assessment: identifying inequitable assets and gaps of health and social services through community engagement

After outreach presentations, collaboration team members led discussions on available regional services for the six WPC-LA focus populations. For instance, if a CBO described support services for low-income mothers, discussions could evolve to describe how WPC-LA initiatives (e.g., doulas) may support their clients and vice versa. Or, if discussions revealed a lack of particular services in their region, the team would compile and report service gaps to WPC-LA leadership. The collaboration team mapped WPC-LA service contracts by SPAs to illustrate region-specific service gaps (e.g., homeless shelters, substance use treatment centers, or reentry services). Additional supportive data sources for service assessments included publicly available data from county agencies, shared lived experiences from focus populations, or feedback from WPC-LA CHWs on local resource availability and accessibility (i.e., limited hours or eligibility). Regional assessments helped identify potential interventions, brought health system staff to community spaces, and elevated community-identified service needs to health system leaders.

Following service assessments, the collaboration team would meet with the LAC DHS leadership and contracts and grants division to strategize improving WPC-LA service partnerships, including creating new grant proposals and contracts or expanding existing contracts for additional services. When specific WPC-LA resources or contracts were unfeasible, the team focused on developing partnership strategies for service gap problem-solving, such as creating a Memorandum of Understanding. For instance, a Memorandum of Understanding between LAC DHS, Los Angeles City jails, and local providers was signed to allow WPC-LA CHWs to refer clients to an existing City Jail Diversion program directly. Another example includes a Memorandum of Understanding between LAC DHS and LAC DPH to refer LAC DHS clients to the LAC DPH Doula program that allows for Doulas in LAC DHS hospitals. The collaboration team's ability to reach direct service staff (i.e., CHWs) and LAC-DHS leadership (including contracts administration) helped support cross-sector, multi-level problem-solving. A collaboration team member describes how focused discussions across the county, including within county services, were novel,

"A success of the WPC pilot on regional cooperation is just getting to a community and identifying the gaps in services and resources, networking and bringing community leader[s] and members, and local politicians involved in these conversations… [it is] another example of what the community, local government, local public health departments, [and] mental health departments can do to affect change."

Phase 3: collaboration team community engagement processes: bridging health and social system collaboration for health equity

The team organized several place-based initiatives to build cross-sector and community-focused capacity to improve equitable services. Case studies describe examples of building new health systems and community engagement processes through countywide action teams and workgroups on justice-system diversion and African American infant and maternal health (see Table 2). As building community engagement processes for health systems within social and medical integration is new, these case studies portray collaboration team community engagement strategies for gaining cross-sector input in health programs and policies for specific populations facing health disparities.

Table 2 Building health system engagement case studies

Initiatives emphasized power-sharing by obtaining community expertise, gaining insight from individuals with lived experience, informing program decision-making, guiding local policy initiatives, and building cross-sector partnerships to address social service gaps. Inclusive engagement process practices included lay-level communications, equal voting privileges for community stakeholders, consensus-building processes, transparent decision-making, and elevating the voice of those with lived experience. A team member explains the strategic inclusion of WPC-LA's target populations as "constantly engaging individuals directly impacted by an issue to participate in a community or government initiative."

For example, one collaboration team member [D.L.] described regional coordination of homeless agencies and hospital stakeholders to conduct strategic planning for the 2019 California SB-1152 Hospital patient discharge planning bill, requiring a hospital to document discharge planning (including shelter or social services) before discharging a homeless patient. The collaboration team developed a working group in their SPA to educate, share information, identify resources, and coordinate planning between local health systems and CBOs.

Another member [D.Z.] described a process of engaging justice systems, justice-involved CBOs, and community members in advocating for incarcerated person's ability to identify family members' disclosure of their medical records. Family disclosure is allowed through the HIPAA Privacy Rule and can promote post-release healthcare continuity and support community reentry. However, it was unavailable through LAC-DHS correctional health. Advocacy was conducted with LAC-DHS WPC-LA leadership, eventually leading to medical record functionality for adding family member HIPAA disclosure in May 2021.

Facilitators identified by the collaboration team in conducting health system community engagement

Collaboration team members noted their prior community expertise, relationships, and lived experience as related to WPC-LA focus populations as a strength in working within promoting cross-sector partnerships. Team members described community representation as an asset for engagement, mutual understanding, and trust-building with community members and CBOs. Members described strengths in internal collaboration team activities for grounding community engagement through weekly team-building and bi-annual retreats. These activities included staff development, wellbeing workshops, discussions on lessons learned from new initiatives, and the development of internal frameworks and strategic plans, including a racial equity and social justice plan. Tools, readings, and frameworks used for team building sessions included community engagement principles [23, 24], human-centered design [25], social change and dismantling racism tools [26, 27], racial identity development readings [28], and various publicly available tools from the Government Alliance on Race and Equity [29,30,31,32,33,34] and Racial Equity Tools websites [35].

Challenges identified by the collaboration team in conducting health system community engagement

Challenges were noted in the initial outreach phase to social service CBOs. Due to the rapid WPC-LA ramp-up for pilot Medicaid funding, where WPC-LA staffing and services varied by SPA in the initial years, WPC-LA programs may have limited capacity or intake processes, limiting clinical referrals. Building CBO relationships was critical to optimize appropriate social service referrals based on currently available WPC-LA services. However, relationship-building took time as CBOs sometimes questioned why overarching healthcare funding mechanisms directly funded health systems for social services referrals instead of directly existing supporting social services organizations. CBOs also asked how WPC-LA programs may overlap with existing community-based social services. In response, some collaboration team members described how they explained the rapid ramp-up phase and openly discussed the program development, resource needs, and challenges. For instance, instead of trying to “sell WPC-LA services” to CBOs, as one collaboration team member stated, they worked with CBOs to identify areas for collaboration, share resources, build partnerships (formally or informally), or support service needs through knowledge sharing.

Collaboration team members described a need for institutional buy-in and longitudinal infrastructure for community engagement processes, including payments or incentives for individuals with lived experience for program design or input, time for partnership building, and a need for health-system-embedded community-engaged career paths funded outside of temporary waiver funding, as the collaboration team staff were unsure of their position’s sustainability following the waiver. Longitudinal planning and collaboration infrastructure were limitations in team, partnership, and collaboration sustainability.

Recommendations and lessons learned for other safety net systems

The Collaboration Team proposed various health system community engagement process recommendations, see Table 3. Recommendations have implications for how health systems can prepare to engage with communities effectively, be more responsive to communities, and partner to address health and social service gaps.

Table 3 Recommendations for community engagement in safety-net systems for social service integration


The newly implemented and dedicated collaboration team provided locally informed communication that allowed for bi-directional knowledge exchange between county services, populations with lived experience facing health disparities, direct service staff (i.e., CHWs), and community-based social services, identifying service gaps and recommendations. Through direct outreach, service assessment, and building community partnerships, collaboration team members engaged cross-county services, CBOs, and community members to facilitate health and social service networks. The collaboration team obtained critical insight through community engagement to improve social and medical service delivery for WPC-LA focus populations, resulting in health system policy recommendations, program changes, and partnerships. This novel team described building cross-sector relationships and workgroups to facilitate outreach, service assessments, and partnerships. Recommendations have implications for other health systems in creating roles for, designing, and conducting community-engaged processes for addressing health disparities, service gaps, and social needs.

The collaboration team provided recommendations for health system community engagement processes and potential institutional changes, including facilitating organizational readiness, building mutually beneficial community partnerships, valuing lived experience, and human resource strategies for incorporating community leadership and staff development in community engagement processes. Calls for institutional change for health system community partnerships described elsewhere include the need for human resource infrastructure supporting community engagement, including time for relationship building and consensus-building, decision-making power and valuing community expertise, bi-lateral problem solving for cross-sector service delivery, and data sharing, sustainable co-funding, and capacity building [1, 10, 36,37,38,39,40,41,42,43,44,45,46,47,48]. Additional issues in navigating cross-sector differences between health systems, social services, and community resources may include not over-medicalizing social services delivery to maintain expertise in community-based, tailored social service delivery [7, 39, 45, 49]. Evidence shows that health services staff can form synergistic community partners; however, institutional change is critical to sustaining healthcare-community partnerships [50]. To achieve this change, participatory processes, such as collective impact, may serve as a tool to improve community engagement, promote social justice, and enhance transparency in health system programming, policy, and budgeting [51,52,53,54].

Scaling social-medical models are challenging in safety-net health systems with limited resources for building and sustaining community partnerships. Early in WPC pilot implementation, many challenges to partnerships were reported not just in LA but statewide, including the need to build new infrastructure supporting effective cross-sector care coordination, sufficient time to ensure partner buy-in, consistent cross-sector communication, sharing care goals for shared clients, aligning financial incentives, and increasing investment in care service gaps [10, 55]. Community engagement processes within health systems may vary widely and lead to different outcomes [9]. LAC DHS hired the WPC-LA Collaboration Team based on lived experience, community ties, and experience with community organizing or social services. As a result, the collaboration team’s personal and professional qualifiers enabled relating to WPC-LA target populations for building trust [56] and connecting and advocating for existing community initiatives promoting social services, well-being, or health. As a result, the community engagement process in WPC-LA may differ from other California Medicaid programs or health system engagement teams (if existent). Additionally, institutional support and the ability to sustain collaboration teams through future California Medicaid funding, such as through CalAIM, will affect cross-sector communication and collaboration implications for addressing the social determinants of health [17, 57].

Limitations include a limited sample size of collaboration team members in one county health system. LAC-DHS is the nation’s second-largest municipal health system and among the most diverse, potentially enhancing the generalizability of some findings. This study focuses on the collaboration team and health system leadership perspectives, potentially differing from feedback obtained from external collaborators, such as WPC-LA CBOs, solicited separately [44]. Lastly, the study was unable to evaluate the impact of the collaboration team on health or social outcomes of WPC-LA populations, service partnerships, cross-sector or community resource connections, or trust, an area ripe for future research. Additionally, COVID-19 may have impacted partnership-building, and more research is needed to understand how the pandemic may have shifted these efforts.


Integrating the coordination of social services into healthcare creates new opportunities and challenges for cross-sector community collaboration and engagement to optimize the design and promote systemic change to improve the quality of care for vulnerable Medicaid populations. A dedicated health system community engagement team allows for bi-directional knowledge exchange between county services and people with lived experience, increasing the capacity for intervening in needed services. Engaging a wide variety of stakeholders, the collaboration team supported collaboration by advocating for community expertise to inform policies, programs, and resource distribution models centered on the experiences of communities most affected by disparities. Future efforts should tailor the collaboration team role to gain community trust, feedback, and insight and to develop new collaborations to address health inequities.

Availability of data and materials

All data analyzed during this study are included in this published article. For any requests about the data from this study, please contact



Community-based organization


Los Angeles County Department of Public Health


Los Angeles County Department of Mental Health


Department of Public Social Services


Los Angeles County Department of Health Services


Service Planning Area


Whole Person Care


Whole Person Care-Los Angeles


  1. Fichtenberg C, Delva J, Minyard K, Gottlieb LM. Health And Human Services Integration: Generating Sustained Health And Equity Improvements: An overview of collaborations, partnerships, and other integration efforts between health care and social services organizations. Health Affair. 2020;39(4):567–73.

    Article  Google Scholar 

  2. Crumley D, Lloyd J, Pucciarello M, Stapelfeld B. Addressing social determinants of health via Medicaid managed care contracts and section 1115 demonstrations. Center for Health Care Strategies. Published 2018. Accessed 27 Feb 2023.

  3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affair. 2008;27(3):759–69.

    Article  Google Scholar 

  4. Bachrach D. Addressing patients' social needs: an emerging business case for provider investment. Commonwealth Fund; 2014.

  5. Horwitz LI, Chang C, Arcilla HN, Knickman JR. Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19: Study analyzes the extent to which US health systems are directly investing in community programs to address social determinants of health. Health Affair. 2020;39(2):192–8.

    Article  Google Scholar 

  6. National Academies of Sciences E, Medicine. Integrating social care into the delivery of health care: Moving upstream to improve the nation's health. 2019.

  7. Kreuter MW, Thompson T, McQueen A, Garg R. Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. Annu Rev Public Health. 2021;42:329.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Wodchis WP, Shaw J, Sinha S, Bhattacharyya O, Shahid S, Anderson G. Innovative Policy Supports For Integrated Health And Social Care Programs In High-Income Countries: An evaluation of innovative policy supports to provide integrated health and social care to high-needs and high-cost populations in high-income countries. Health Affair. 2020;39(4):697–703.

    Article  Google Scholar 

  9. Mullins CD, Wingate LMT, Edwards HA, Tofade T, Wutoh A. Transitioning from learning healthcare systems to learning health care communities. J Comp Eff Res. 2018;7(6):603–14.

    Article  PubMed  Google Scholar 

  10. Chuang E, Pourat N, Haley LA, O’Masta B, Albertson E, Lu C. Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration: An overview of a California demonstration program focused on improving the integrated delivery of health, behavioral health, and social services for certain Medicaid beneficiaries. Health Affair. 2020;39(4):639–48.

    Article  Google Scholar 

  11. California Department of Health Care Services (DHCS). Whole Person Care Pilot Application. Sacramento, CA: California Department of Health Care Services; 2017.

  12. Medi-Cal. Transformation of Medi-Cal: Community Supports, Supplemental Fact Sheet. Sacramento, CA: California Department of Health Care Services (DHCS); 2023. Accessed 27 Feb 2024.

  13. Pourat N, O’Masta B, Haley L, Chuang E. Policy Brief: A Snapshot of California’s Whole Person Care Pilot Program: Implementation Strategies and Enrollees. Los Angeles: UCLA Center for Health Policy Research; 2021.

  14. Kim K, Choi JS, Choi E, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: a systematic review. Am J Public Health. 2016;106(4):e3–28.

    Article  PubMed  PubMed Central  Google Scholar 

  15. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

    Article  PubMed  Google Scholar 

  16. King O. Two sets of qualitative research reporting guidelines: An analysis of the shortfalls. Res Nurs Health. 2021;44(4):715–23.

    Article  PubMed  Google Scholar 

  17. Berkowitz B. Collaboration for health improvement: models for state, community, and academic partnerships. J Public Health Man. 2000;6(1):67–72.

    CAS  Google Scholar 

  18. Milstein B, Wetterhall S. Recommended framework for program evaluation in public health practice. Morbidity and Mortality Weekly Report: Recommendations and Reports Series. 1999.

  19. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–97.

    Article  Google Scholar 

  20. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328–52.

    Article  Google Scholar 

  21. Braun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be (com) ing a knowing researcher. Int J Trans Health. 2023;24(1):1–6.

    Article  Google Scholar 

  22. Tracy SJ. Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qual Inq. 2010;16(10):837–51.

    Article  Google Scholar 

  23. González R. The Spectrum of Community Engagement to Ownership. Facilitating Power, Oakland, CA: Movement Strategy Center; 2019.

    Google Scholar 

  24. Schoch-Spana M, Franco C, Nuzzo JB, Usenza C, Working Group on Community Engagement in Health Emergency P. Community engagement: leadership tool for catastrophic health events. Biosecur Bioterror. 2007;5(1):8–25.

    Article  PubMed  Google Scholar 

  25. Hasso Plattner Institute of Design at Stanford University. Resource Collection. Liberatory Design. Equity-Centered Design Framework. Hasso Plattner Institute of Design at Stanford University, 2021. Accessed 27 Feb 2024.

  26. Jones K, Okun T. White supremacy culture. Dismantling racism: A workbook for social change groups. 2001.

  27. Coskun A, Erbuğ Ç. User diversity in design for behavior change. 2014:546–559.

  28. Wijeyesinghe C, Jackson BW. New perspectives on racial identity development: Integrating emerging frameworks. NYU Press; 2012.

  29. Nelson J, Brooks L. Racial Equity Toolkit An Opportunity to Operationalize Equity. Government Alliance on Race and Equity (GARE). Published 2016. Accessed November 5, 2020, 2020.

  30. Nelson J, Spokane L, Ross L, Deng N. Advancing Racial Equity and Transforming Government: A Resource Guide to Put Ideas Into Action Government Alliance on Race and Equity (GARE);2015.

  31. Lohrentz T. Contracting for Equity: Best Local Government Practices that Advance Racial Equity in Government Contracting and Procurement. Government Alliance on Race & Equity (GARE);2015.

  32. Nelson J, Tyrell S. Public Sector Jobs: Opportunities for Advancing Racial Equity. Government Alliance on Race and Equity (GARE);2015.

  33. Curren R, Nelson J, Marsh DS, Noor S, Liu N. Racial Equity Action Plans: A How-to Manual. Government Alliance on Race and Equity (GARE);2016.

  34. Keleher T. Racial Equity Core Teams: The Engines of Institutional Change. Government Alliance on Race and Equity (GARE);2018.

  35. Racial Equity Tools. Racial Equity Tools. Accessed 5 Nov 2020.

  36. Bromley E, Figueroa C, Castillo EG, et al. Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders’ Views of its Promise and Challenge. Ethn Dis. 2018;28(Suppl 2):397–406.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ward CJ, Child C, Hicken BL, et al. “We Got an Invite into the Fortress”: VA-Community Partnerships for Meeting Veterans’ Healthcare Needs. Int J Environ Res Public Health. 2021;18(16):8334.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Amarashingham R, Xie B, Karam A, Nguyen N, Kapoor B. Using community partnerships to integrate health and social services for high-need, high-cost patients. Issue Brief (Commonweath Fund). 2018;2018:1–11.

    Google Scholar 

  39. Taylor LA, Byhoff E. Money moves the mare: the response of community-based organizations to health care’s embrace of social determinants. Milbank Q. 2021;99(1):171–208.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Lanford D, Petiwala A, Landers G, Minyard K. Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data. Health Soc Care Community. 2022;30(2):432–47.

    Article  PubMed  Google Scholar 

  41. Zahner SJ. The mobilizing action toward community health partnership study: multisector partnerships in US counties with improving health metrics. Prev Chronic Dis. 2014;11:E05.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Woulfe J, Oliver TR, Siemering KQ, Zahner SJ. Peer reviewed: Multisector partnerships in population health improvement. Prev Chronic Dis. 2010;7(6).

  43. Siegel B, Erickson J, Milstein B, Pritchard KE. Multisector partnerships need further development to fulfill aspirations for transforming regional health and well-being. Health Affair. 2018;37(1):30–7.

    Article  Google Scholar 

  44. Agonafer EP, Carson SL, Nunez V, et al. Community-based organizations’ perspectives on improving health and social service integration. BMC Public Health. 2021;21(1):452.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Sandhu S, Sharma A, Cholera R, Bettger JP. Integrated Health and Social Care in the United States: A Decade of Policy Progress. Int J Integr Care. 2021;21(4):9.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Sacks E, Morrow M, Story WT, et al. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health. 2019;3(Suppl 3):e001384.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Castrucci B, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. 2019;10.

  48. Durfey SN, Gadbois EA, Meyers DJ, Brazier JF, Wetle T, Thomas KS. Health Care and Community-Based Organization Partnerships to Address Social Needs: Medicare Advantage Plan Representatives’ Perspectives. Med Care Res Rev. 2021;79(2):10775587211009724.

    Google Scholar 

  49. Hardin L, Trumbo S, Wiest D. Cross-sector collaboration for vulnerable populations reduces utilization and strengthens community partnerships. J Interprofessional Educ Pract. 2020;18:100291.

    Article  Google Scholar 

  50. Nathan S, Harris E, Kemp L, Harris-Roxas B. Health service staff attitudes to community representatives on committees. J Health Organ Manag. 2006;20(6):551–9.

    Article  PubMed  Google Scholar 

  51. Costa-Font J, Forns JR, Sato A. Participatory health system priority setting: Evidence from a budget experiment. Soc Sci Med. 2015;146:182–90.

    Article  PubMed  Google Scholar 

  52. Noonan AS, Velasco-Mondragon HE, Wagner FA. Improving the health of African Americans in the USA: an overdue opportunity for social justice. Public Health Rev. 2016;37(1):1–20.

    Article  Google Scholar 

  53. Almgren G. Health care politics, policy, and services: a social justice analysis. Springer publishing company; 2017.

  54. Kania J, Williams J, Schmitz P, Brady S, Kramer M, Juster JS. Centering equity in collective impact. Stanf Soc Innov Rev. 2022;20(1):38–45.

    Google Scholar 

  55. Chuang E, O’Masta B, Albertson E, Haley L, Lu C, Pourat N. Policy Brief: Whole Person Care Improves Care Coordination for Many Californians Los Angeles: UCLA Center for Health Policy Research;2019.

  56. American Association of Medical Colleges. The Principles of Trustworthiness. American Association of Medical Colleges. Published 2021. Accessed 8 Apr 2022.

  57. Parker E, Margolis LH, Eng E, Henriquez-Roldan C. Assessing the capacity of health departments to engage in community-based participatory public health. Am J Public Health. 2003;93(3):472–6.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Los Angeles County Alternatives To Incarceration Workgroup. Care First, Jails Last: Health and Racial Justice Strategies for Safer Communities Chief Executive Office, County of Los Angeles;2020.

  59. Los Angeles County Alternatives to Incarceration Workgroup. Countywide Diversion Programs Evaluation Processes Spreadsheet. Los Angeles County, Alternatives to Incarceration Workgroup. Work Group Documents & Resources Web site. Published 2019. Updated 5/10/2019. Accessed.

  60. Los Angeles County Alternatives to Incarceration Workgroup. Community Resources for Alternatives to Incarceration in Los Angeles, CA, USA. Published 2020. Accessed 4 Nov 2020.

  61. Tchekmedyian A. L.A. County seeks plan to close aging Men’s Central Jail in a year. Los Angeles Times. 7Jul 2020 2020.

  62. Los Angeles County Chief Executive Office. Alternative Crisis Response (ACR). Los Angeles County Chief Executive Office. Published 2020. Accessed 7/19/2022.

  63. Los Angeles County Executive Office, Los Angeles County Board of Supervisors, Los Angeles County Counsel, Los Angeles County Measure J Advisory Panel Chair, Los Angeles County Alternatives To Incarceration Workgroup, Los Angeles County Anti-Racism Diversity and Inclusion. Financial Year 2021–2022 Measure J Recommended Set-Aside. Los Angeles County, CA: Los Angeles County Executive Office;  2021.

  64. Los Angeles Mommy and Baby Project (LAMB). 2016 Surveillance Report. In: Department of Public Health M, Child & Adolescent Health Division (MCAH), ed. Los Angeles County Department of Public Health; 2016.

  65. California ACLUA, USA BP, Wellness BWf, et al. Birthing People's Bill of Rights COVID-19 Edition. South Los Angeles/South Bay African American Infant and Mortality Community Action Team;2020.

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Thank you to Members of the Los Angeles County Department of Health Services (LAC DHS), Whole Person Care-Los Angeles (WPC-LA) Collaboration Team, and Leadership for their input, guidance, time, and efforts in this work.


This research is supported by NIH National Center for Advancing Translational Science (NCATS) grant UL1TR001881 (UCLA).

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All authors made substantial contributions, approved the submitted version, and have agreed both to be personally accountable for the author’s contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even one in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. The study design was conducted in collaboration with all authors. S.C. and F.C. conducted the primary analysis and wrote the main manuscript text. A.B., E.A., D.L., C.H., and D.Z provided manuscript editing and feedback. All authors reviewed the manuscript.

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Correspondence to Savanna L. Carson.

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Carson, S.L., Cameron, F., Lee, D. et al. A collaboration team to build social service partnerships within a safety-net health system. BMC Public Health 24, 654 (2024).

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