What Are We Learning about Systems Alignment?

A large and growing body of evidence demonstrates how social determinants shape health across the lifespan and inter-generationally, including factors such as poverty, discrimination, lack of access to good jobs with fair pay, poor educational opportunities, food insecurity, exposure to household and community violence, and involvement with the criminal justice system. Unfortunately, the services and supports designed to intervene on these determinants – such as housing, transportation, educational reforms, and legal services and supports – are often disconnected from the medical services and public health programs tasked with improving health. As a result, medical and public health interventions often fall short in improving health and health equity because they fail to adequately address underlying social, economic and environmental conditions.

Over the past several years, there has been an explosion of pilots, demos, and trials of multi-sector initiatives designed to build stronger connections among medical, social, and public health systems. This rapid innovation is impressive and encouraging, but unfortunately the research community has not kept pace, raising concerns about sustainability and unintended consequences. How will we know what works, and do we need to wait for years to find out?

Our research program, Systems for Action (S4A) , has been working hard to put strong research designs around these initiatives so that we can produce strong evidence about what works, where, for whom and why. As a signature research program of the Robert Wood Johnson Foundation (RWJF), the S4A program builds a Culture of Health by rigorously testing new ways of connecting the nation’s fragmented medical, social, and public health systems. Studies conducted through the S4A program test innovative mechanisms for aligning delivery and financing systems for medical, social, and public health services, with a focus on estimating the effects of these mechanisms on health and health equity.

The system alignment mechanisms we study take many forms, including shared governance models, platforms for data exchange and integration, bundled and blended payment models, and cross-cutting workforce components such as navigators and integrators. Over the past 4 years, more than 25 studies have been implemented through S4A to identify which alignment mechanisms work best for which populations and in what community circumstances. And we are in good company, as other federal and philanthropic initiatives have begun to sponsor research on multi-sector approaches to population health improvement.

Special AJPH Supplement Issue: Aligning Systems

To synthesize and spread the emerging evidence from this growing area of research, we are collaborating with the American Journal of Public Health to produce a special supplement issue on health and social system alignment. This issue will feature the latest findings from studies of system alignment models tested in communities across the U.S.–including a careful examination of both successes and failures—along with discussions of the policies and practices needed to spread and sustain promising models. This issue will prioritize empirical research articles that offer evidence about the implementation and impact of system alignment strategies, but we will also consider other types of AJPH manuscripts such as analytic essays, and field reports on innovations in practice. This issue will appear in print and online in summer 2020.

Submissions for this issue must be received by December 15, 2019 through the AJPH submission website. Importantly, submissions must include a cover letter formatted as requested in the AJPH Instructions for Authors, and should specify that the submission is for the special supplement issue on “Aligning Health and Social Systems.” Please visit the AJPH website to review instructions for authors and specific guidelines for manuscript submission.