The Organizational Risks Of Cross-Sector Partnerships: A Comparison Of Health And Human Services Perspectives

Cross-sector collaboration between health and human services organizations is increasingly proposed as a promising strategy for addressing social determinants of health.^1,2 While a growing body of research documents the challenges of working in cross-sector partnerships,^3–5 less is known about how health and human services leaders decide to collaborate in the first place. What factors do organizational leaders weigh when considering collaborative opportunities, and what do they worry about?⁶

Risk perception—the belief that an undesirable outcome may occur in the future—is an important factor in whether and how organizational leaders decide to collaborate.^6,7 Collaborative risks may include not only the potential for new costs or liabilities but also uncertainty about others’ intentions and behaviors and the potential for reputational damage. Leaders’ risk perceptions are more than speculative worries about the future: They have the potential to shape behavior in ways that may have consequences for the success or failure of cross-sector partnerships.⁸

Risk perceptions are highly context specific, even among people faced with the same regional challenges or collaborative opportunities.⁸ Collaborating to address social determinants of health has been described as a collective action dilemma.⁹ While it may benefit a community, individual organizations may be disincentivized to collaborate when they do not perceive that the benefits outweigh the risks for their specific organizations or sectors.¹⁰ Differences in health and human services leaders’ risk perceptions may represent untapped opportunities to cultivate trust and more clearly align incentives for collaboration between the sectors, but these differences are not well documented.

This article explores this gap in the literature through a case study of a subset of health and human services organizations that were engaged in the Centers for Medicare and Medicaid Services’ Accountable Health Communities (AHC) initiative in Oregon in 2019.¹¹ We used a theoretical framework of decision making in collective action dilemmas⁸ to explore how leaders perceived the risks of collaboration for their organizations, and how their perceptions shaped their willingness to work across sector lines in the early stages of the project.

Study Data And Methods

Setting

Oregon’s Accountable Health Communities project is administered by staff from the Oregon Rural Practice-Based Research Network and was launched in May 2017. The AHC project provides participating organizations with a per screen payment for performing social needs screening of qualifying people enrolled in Medicaid, Medicare, or both.¹¹ Project staff recruited organizations from four rural regions to conduct screening, referral, and navigation activities. People identified through screening as having unmet needs for housing, food, transportation, or utilities or being at risk for interpersonal violence are provided with a list of programs in their region where they can seek assistance. High-risk people receive personal navigation help to assist them in connecting to community resources.

At the time of this research, these organizations had received initial training and technical assistance from Oregon Rural Practice-Based Research Network staff and had recently begun screening patients and providing referrals to human services organizations. Additional outreach activities to human services organizations in the AHC project were just beginning. This study was conducted by one of the authors (Petchel) who is not affiliated with the Oregon Rural Practice-Based Research Network but who worked in consultation with network staff to identify research participants and coordinate communications about the study.

Participant Recruitment

Participants were leaders of health and human services organizations that were recruited in two phases from the four AHC regions in Oregon. Two or three health services organizations were identified from among the screening organizations in each region in consultation with Oregon Rural Practice-Based Research Network staff. Organizations that had begun screening patients by May 2019 were prioritized and were then selected for maximum variation among primary care, public health, and oral health services. A list of potential human services organizations was developed by one of the authors (Petchel) through a review of community resource lists generated by the project’s data system in the period April–June 2019. Three or four human services organizations were identified from each region, maximizing variation among five resource categories (food, housing, transportation, utilities, and safety) and avoiding duplication of resource types in any region (see below).

Data Collection And Analysis

This study used a theoretical framework for understanding decision making in collective action dilemmas. In this framework, individuals weigh the appropriateness of collaborative behavior according to their identity (including their obligations to their organization’s stakeholders and history or experience with collaborations); their perception of the problem to be solved; and the “task structure” of the potential collaboration (such as the perceived motives or trustworthiness of potential partners and the ease of communication or information sharing).⁸

All data were collected in the period April–July 2019. Participants first completed an online survey to provide details about their organization’s size, services, and partnerships. They then completed a semistructured phone interview with one of the authors (Petchel) that addressed perspectives on the risks and benefits of cross-sector collaboration, ideological and operational considerations, and experiences working with organizations from other sectors. Additional documents, such as community health improvement plans, were collected when offered by participants. Survey responses were analyzed using Qualtrics software. Interviews and documents were coded and thematically analyzed in Atlas.ti software, version 8.2.1, by one of the authors (Petchel), who used a coding schema developed from the theoretical framework. Themes were refined and clarified through discussion among the three authors.

All protocols were approved by the Portland State University Institutional Review Board (Protocol No. 194920).

Limitations

Our study had several limitations. First, the views of the participants in this research are not intended to be representative of their respective industries or regions as a whole. While this research explored differences in the perspectives of health and human services leaders, meaningful differences also exist within sectors that were beyond the scope of this article.

Second, this research occurred early in the implementation of the AHC project in Oregon, and these participants’ views may have changed over time.

Third, leadership perspectives on cross-sector collaboration in other locations may vary.

Study Results

The Accountable Health Communities project in Oregon was implemented against a backdrop of state health reforms, including the creation of coordinated care organizations (CCOs) in 2014 to locally govern the provision of care to Medicaid enrollees¹² and, beginning in 2020, the launch of the state’s initiative that directs all CCOs to develop strategies for addressing social determinants of health.¹³ The climate of health system reform provides important context for our findings, since all participants but one identified multiple co-occurring cross-sector efforts in their regions. Examples included CCO community advisory councils, other screening and referral initiatives, case management groups, and direct service agreements with other organizations. Many human services organizations were not yet aware of the AHC project at the time the research began but were generally familiar with efforts by their local health systems to identify people with unmet social needs and refer them to community programs.

The final study population consisted of representatives of nine health services and thirteen human services organizations (exhibit 1), with one organization having two representatives. The organizations were evenly distributed among the four AHC regions: There were six each in the Yamhill Valley and Rogue Valley, and five each in Central Oregon and mid-Columbia Gorge (data not shown). Participants held leadership positions within their organizations and identified themselves as playing a central role in influencing their organizations’ decisions about community partnerships.

Both health and human services leaders weighed the perceived risks and benefits of collaboration in deciding how to work with organizations from other sectors. Participants spoke broadly about how their histories working with local partners informed their perspectives on future collaborative opportunities such as AHC. Their perceptions of the risks of collaboration are best understood as an accumulation of these experiences with these partners over time, rather than their views of a single effort such as the AHC project. Perceived risks manifested themselves differently, depending on the values and motives of individuals and their organizations, as well as their perceived options and constraints. These differences are summarized in exhibit 2 and explored further below.

Value Of Screening And Referral Networks

Health and human services leaders described the value of participating in screening and referral networks differently. Health services leaders perceived value in collecting data on unmet social needs that could be used to inform community planning and advocate for additional funding. One health services leader stated: “What we’re hoping to get out of this is to know what resources we are missing. Then it’s up to us as a community to act on those shortages and try to overcome them.” In contrast, some human services leaders believed that they already possessed data that health services organizations were trying to collect. They were more likely to perceive value in streamlining efforts, noting that clients sometimes received redundant screenings and inadequate support following identification of an unmet need. As one manager stated, “[The screenings] seem to be layered on top of one another.”

Several participants expressed concern that referral networks alone were not sufficient to coordinate services in the absence of further relationship building or program investments. Participants described the lack of community resources rather than barriers to access as the limiting factor they worried would ultimately hinder the success of cross-sector collaborations. As one human services leader noted: “The problem is lack of services. I rarely run into nonprofits I respect that have trouble finding people to serve.” Others perceived missed opportunities to collaborate on service coordination as a result of lack of interorganizational relationships.

Reputation With Stakeholders

Both health and human services leaders considered how collaborations would be perceived by staff and board members and described a responsibility to justify new efforts to them. Health services leaders considered the potential burden on staff and impact on retention from new work flows and uncomfortable conversations about social needs. One participant said, “It can be really difficult to keep employees motivated when you’re continually asking for one more thing.” Health services leaders also worried about the risk to their organization’s reputation if they were not able to achieve targets for screenings. One leader stated, “We want to deliver on what we agreed to do, so we chose sites with staff that would make this a priority to meet those target numbers.”

In contrast, human services leaders worried that when collaboration required changes in operations, it could be perceived as “chasing funding” at the expense of adherence to the organization’s mission—which could undermine leadership credibility. One leader noted, “Like most nonprofits, we tend to struggle with chasing funding that pulls us off track.” Human services leaders also worried that new work would be perceived as co-opting programs or projects led by other human services organizations in their community. As one leader stated: “We look at who else is doing that type of work, and are we stepping on anybody’s toes? You don’t want to start something identical if it’s already going on.”

Financing And Sustainability Of Services

Both groups of participants spoke of their responsibility to identify sustainable sources of funding, but interviews revealed differences in how leaders from the two sectors believed cross-sector collaboration supported their financial sustainability. Among health services leaders, cross-sector collaboration was perceived as a necessary element of population health management, as their organizations sought to transition from a fee-for-service model. One participant said: “We were at an alternative payment model meeting. One way that a lot of clinics were focusing on that work was through the AHC project.” In contrast, human services leaders spoke of collaboration with health services organizations as an opportunity to move toward fee-for-service arrangements, which were perceived as more sustainable than grants and donations. One leader said, “When we’re contracted with [health care] agencies, that fee-for-service type of income helps with our sustainability.”

Relationships And Power Dynamics

Despite a desire to learn about one another and discuss shared challenges and solutions, most health and human services leaders described struggling to make time for relationship building. Among health services organizations, this was manifested as not being able to make time to participate in community meetings or calls that would help them identify potential partners and learn about their work. Human services leaders described being overwhelmed by the number of regional meetings they were invited to attend and struggling to prioritize among them.

Leaders from both sectors perceived large health systems, hospitals, and CCOs as having power to promote or hinder cross-sector collaboration in their region by establishing “the table” where partners gathered and regional priorities were selected. One human services leader stated: “The lack of coordination among human services and health services is because if health care organizations are in charge of a meeting, then it’s mandatory. If anyone else is in charge, then it’s optional, and they don’t come to the table.”

Also, leaders from both sectors described the formation of CCOs^12,13 as a key milestone for cross-sector collaboration in their regions because of the CCOs’ mandate to establish community advisory committees and develop regional health improvement priorities. CCOs were also identified by both groups as the principal funder of regional collaboration to address social determinants of health, and securing support from the relevant CCO (both financially and politically) was a key factor in deciding to pursue new partnerships.

In contrast to the perceived power of health systems and CCOs, other providers (including human services, mental health, and peer support providers and small medical practices) were perceived as lacking power in cross-sector collaborations. These power differences were described as a risk because organizations that lacked power were less able to hold partners accountable. One human services leader stated: “It would be hard for us to go to [a health system] and say, ‘You haven’t done your part.’ It would be easily dismissed as ‘You guys are small. We’re big. We have other priorities.’”

While both health and human services leaders emphasized the importance of interpersonal relationships in overcoming these perceived power differences, participants in both sectors also described the challenge of trying to identify the right point of contact at partner organizations and the risk that relationships could be undermined because of staff turnover. One health services leader stated, “When a partner has high staff turnover, you’re always rebuilding that relationship, reestablishing who you are.” One human services leader noted that because of differences in organization size, it was difficult to reach the leaders at the local health system to discuss collaboration: “Their decision makers are far removed from the ground level. It’s more than not knowing the language each other is speaking.”

Competing For Workforce And Credit

While health and human services leaders rarely cited competition for market share or clients as a risk in collaboration, competition was manifested in other ways, such as for workers. Human services leaders noted that co-locating employees with health services partners risked having those employees hired away or identifying more strongly with their host organization than with their employer. When health and human services organizations employed people in similar positions, such as clinical social workers, some leaders perceived a risk of competition for these staff members. Smaller health and human services organization leaders described being in competition with large health systems and CCOs for skilled employees. One human services leader said: “They pay more than what nonprofits can pay. Now we’re in competition for employees, and we can’t compete.”

Some participants also described tension in claiming credit within or among cross-sector initiatives. One human services leader, frustrated that a new health system initiative was perceived to be competing for funding with existing charitable programs, stated: “That’s what I have trouble with. Good things are already happening, and they take credit and take money out of the community that could be used for something else.”

Categorical Restrictions On Funding

Health and human services leaders described their client populations differently, in ways that mirrored differences in their funding streams. Health services leaders described their clients in terms of residence and insurance status, while human services leaders defined beneficiaries as groups such as low-income seniors or people experiencing homelessness. These differences in client definitions were described as a risk when forming new cross-sector partnerships. Human services leaders perceived risk in partnering with organizations whose scope was broader than their own and being out of compliance with funder requirements by providing service to people who were categorically ineligible. One stated, “We have rules about who we can and cannot serve, so that’s probably the biggest factor.”

In contrast, health services leaders expressed a desire that their programs treat individuals the same regardless of insurance status. For example, one said: “We’re doing that work payer-blind, which was really important to me. A lot of people need resources because of circumstances like domestic violence that have nothing to do with a payer.”

Responsibility To Clients

Both health and human services leaders described the importance of incorporating clients’ perspectives into their decision making, including through advisory councils. However, human services leaders perceived an ideological tension with health services organizations regarding the importance of client autonomy. Some participants perceived health initiatives as deliberately restricting individual choice (for example, limiting the availability of certain items at food pantries), and others expressed concerns that people might be directed toward resources in ways that were coercive (such as promoting a particular health partner at a resource fair). One human services leader explained: “We are very careful if it is going to be sole sourcing them to a specific service provider. We don’t want them to be pushed to do a certain thing. It can’t be building business for somebody.” Notably, while participants perceived risks in sharing client data (such as agencies exchanging information about the outcome of a referral), these risks were described in terms of professional obligations such as attorney-client privilege or domestic violence advocate privilege, rather than privacy or compatibility issues related to data exchange.

Discussion

The differences in how health and human services leaders participating in Accountable Health Communities in Oregon described their perceptions of risk in cross-sector collaborations have implications for the design and governance of initiatives to address social determinants of health, and they reveal opportunities to promote cross-sector collaborations through policy.

Implications For Design And Governance

Differences were noted in how participants described their perceptions of risk in direct partnerships with other service delivery providers, as compared to broader initiatives that take a collective impact approach (for example, convening groups of organizations around a shared agenda or goals, often facilitated by a “backbone” entity or lead convener).¹⁴ Direct partnerships (such as a primary care clinic’s hosting a mobile food pantry or embedding a domestic violence advocate within a health care team) tended to be described positively across sectors as having strong mission alignment for the organizations involved. Whether these collaborative efforts were perceived to be worthwhile depended on the degree to which a partner organization appeared to understand one’s philosophy and operations and on a demonstrated willingness to help raise awareness of one’s services in the community. These criteria were key to overcoming reservations about partners’ motives or reliability.

These findings suggest that there are opportunities for policy makers to promote local cross-sector partnerships by investing in regional strategies that help health and human services leaders connect with one another and cultivate a deeper understanding of one another’s service delivery models. Workforce initiatives, such as the Interprofessional Student Hotspotting Learning Collaborative of the National Center for Complex Health and Social Needs, have shown promise in creating regional training hubs to develop students’ skills for working in interdisciplinary teams.¹⁵ Similar training-based approaches may hold promise for developing interprofessional connections at the leadership level and cultivating emerging leaders and program managers who have “boundary spanning” skills to champion collaboration across sectors.¹⁶

Larger cross-sector collaborations that involve many partners or take a collective impact approach were described by participants as potentially coercive, or a means by which larger organizations could exploit smaller or less powerful partners. This risk of exploitation was perceived through pressure to adopt another organization’s goals in lieu of one’s own or to share or collect data that would primarily benefit another organization rather than one’s own. The burden of data collection should be weighed carefully in the design of cross-sector initiatives,¹⁷ particularly in light of human services leaders’ perception of redundant screening efforts and health services leaders’ perceived risk of exacerbating staff retention challenges.

Despite these perceived risks, one of the primary motivations across both sectors for participating in these larger cross-sector initiatives was a desire to match regional investments with community resource needs. One shared value proposition for the health and human services organizations was in the potential for influencing more accountable decision making about regional health priorities. There may be opportunities to link screening and referral projects such as Accountable Health Communities to existing community health needs assessments and engage human services partners in identifying existing local social needs data that are underused for population health planning or community information exchange.¹⁸

Population health initiatives that aim to engage many partners at the regional level may also benefit from considering the ways in which structural inequities or power differences emerge when organizations that prioritize serving different populations or advocate different interests are asked to strategically align their efforts.¹⁹ The emphasis on shared regional goals in efforts such as community health improvement plans had clearly created a sense that some organizations were winners and others were losers: Those whose priority populations or issues were not adopted by the group sometimes felt marginalized by their community partners. When adopting regional priorities, organizations such as CCOs that act as conveners should be mindful of differences in organizations’ size, scope, and resources and consider how to engage partners whose issues or priority populations are important to community health but might not rise to the top of the collective agenda.¹⁹ Health services leaders should also be mindful of the importance of client self-determination in social service delivery, when this value may be in tension with health promotion strategies.²⁰

Policy Opportunities

Health and human services leaders perceived risk in cross-sector collaborations when there was a potential mismatch in service populations. Misalignment of eligibility criteria across federal health and human services programs is a documented issue,²¹ and policy makers may be able to promote local cross-sector collaborations through stronger upstream alignment of categorically defined populations across health and human services policy. In particular, benefit eligibility criteria within the Older Americans Act of 1965 (such as for Meals on Wheels or transportation assistance) were cited as an important consideration that was weighed by human services leaders in partnering locally with organizations such as hospitals.²²

State policy makers may also seek to align local quality and incentive measures with definitions used in human services policy to facilitate data sharing, cross-sector planning, and evaluation.^23,24 This research found that the sharing of credit for outcomes of health and human services collaborations warrants greater attention from policy makers, organizational leaders, and scholars, as both the health and human services sectors seek ways to better evaluate the impact of cross-sector collaborations.²³

Finally, health and human services leaders perceived that investing time in cross-sector relationship development within regional initiatives was a risky endeavor because of uncertain outcomes, lack of sustainable funding, and the potential for competition for resources.^3–5 Policy makers may be able to reduce the perceived risks of cross-sector efforts by ensuring that interorganizational learning and relationship development are explicitly encouraged and supported as community-level population health strategies. The desire among human services leaders to adopt fee-for-service payment models also deserves greater exploration, given the health sector’s current focus on alternative payment methods. As states experiment with road maps to accelerate the adoption of value-based payment and provide guidance on allowable expenditures for flexible services, cross-sector service coordination and monitoring efforts could be supported as programmatic rather than administrative activities in funding mechanisms for both health and human services organizations, and new incentives could be introduced to offset these capacity-building costs.^25,26

Conclusion

Cross-sector collaboration requires organizations to adopt new models for coordinating their work while retaining the best practices of their fields.

Cross-sector collaboration to address social determinants of health requires health and human services organizations to adopt new models for coordinating their work while retaining the best practices of their respective fields. This research found that leaders in both fields perceived risk in cases where partnerships may require their organizations to take actions in conflict with their regulatory or funding requirements or to violate social or professional norms within their fields. Lack of trust in cross-sector partners was attributed to weak interorganizational relationships, low levels of understanding of one another’s service models, and perceived risk of exploitation in regional planning and goal setting.

While this research found differences in how health and human services leaders think about the risks of cross-sector collaborations, it also revealed opportunities to cultivate interprofessional understanding, build trust, and incentivize cooperation across sector lines. Policy can promote cross-sector collaboration at the state and local levels through more direct support for the time and resources necessary for organizations to engage in interprofessional learning, cross-sector networking, and relationship development. Better alignment of service population definitions and quality measures in federal and state health and human services policy may reduce the perceived risks of entering into cross-sector partnerships at the local level. Screening and referral initiatives such as Accountable Health Communities that aim to coordinate health and human services delivery can also benefit from a design that incorporates the values and experience of both sectors and aims to balance the benefits and risks for all partners.

ACKNOWLEDGMENTS

Bruce Goldberg provides consultant services on health policy and health care delivery to the following organizations, which are primarily nonprofits, foundations, or consulting firms, on projects supporting states or nonprofits: Montana Health Care Foundation; Milbank Memorial Fund; Oregon Community Foundation; Native American Rehabilitation Association; TenFold Health; Manatt, Phelps & Phillips; Artemis Consulting; and Better Health Together. None of the consultant services are related to the topic of this article. The authors acknowledge Billie Sandberg of Portland State University and Neal Wallace of Oregon Health & Science University and Portland State University for assistance in research conceptualization. The authors thank Anne King of the Oregon Rural Practice-Based Research Network and Sankirtana Danner of Northwestern University for assistance with participant recruitment. The authors are solely responsible for the content of this article.

NOTES

• 1 Trujillo MD, Plough A. Building a culture of health: a new framework and measures for health and health care in America. Soc Sci Med. 2016;165:206–13. Crossref, Medline, Google Scholar
• 2 Towe VL, Leviton L, Chandra A, Sloan JC, Tait M, Orleans T. Cross-sector collaborations and partnerships: essential ingredients to help shape health and well-being. Health Aff (Millwood). 2016;35(11):1964–9. Go to the article, Google Scholar
• 3 Kadushin C, Lindholm M, Ryan D, Brodsky A, Saxe L. Why it is so difficult to form effective community coalitions. City Community. 2005;4(3):255–75. Crossref, Google Scholar
• 4 Erickson J. Multi-sector partnerships have the potential to transform health, but most aren’t there yet. Health Affairs Blog [blog on the Internet]. 2018 Jan 26 [cited 2020 Feb 10]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20180124.947710/full/ Google Scholar
• 5 Gray B, Purdy J. Collaborating for our future: multistakeholder partnerships for solving complex problems. Oxford: Oxford University Press; 2018. Crossref, Google Scholar
• 6 Carr JB, Hawkins CV, Westberg DE. An exploration of collaboration risk in joint ventures: perceptions of risk by local economic development officials. Econ Dev Q. 2017;31(3):210–27. Crossref, Google Scholar
• 7 Feiock RC. The institutional collective action framework. Policy Stud J. 2013;41(3):397–425. Crossref, Google Scholar
• 8 Weber JM, Kopelman S, Messick DM. A conceptual review of decision making in social dilemmas: applying a logic of appropriateness. Pers Soc Psychol Rev. 2004;8(3):281–307. Crossref, Medline, Google Scholar
• 9 Nichols LM, Taylor LA. Social determinants as public goods: a new approach to financing key investments in healthy communities. Health Aff (Millwood). 2018;37(8):1223–30. Go to the article, Google Scholar
• 10 Kollock P. Social dilemmas: the anatomy of cooperation. Annu Rev Sociol. 1998;24:183–214. Crossref, Google Scholar
• 11 Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable Health Communities—addressing social needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8–11. Crossref, Medline, Google Scholar
• 12 McConnell KJ. Oregon’s Medicaid coordinated care organizations. JAMA. 2016;315(9):869–70. Crossref, Medline, Google Scholar
• 13 Oregon Health Authority, Health Policy and Analytics Division. CCO 2.0 recommendations of the Oregon Health Policy Board [Internet]. Portland (OR): OHA; 2018 Oct [cited 2020 Feb 10]. Available from: https://www.oregon.gov/oha/OHPB/CCODocuments/2018-OHA-CCO-2.0-Report.pdf Google Scholar
• 14 Kania J, Kramer M. Collective impact. Stanford Social Innovation Review [serial on the Internet]. 2011 [cited 2020 Feb 10]. Available from: https://ssir.org/articles/entry/collective_impact Google Scholar
• 15 Bedoya P, Neuhausen K, Dow AW, Brooks EM, Mautner D, Etz RS. Student hotspotting: teaching the interprofessional care of complex patients. Acad Med. 2018;93(1):56–9. Crossref, Medline, Google Scholar
• 16 Tushman ML. Special boundary roles in the innovation process. Adm Sci Q. 1977;22(4):587–605. Crossref, Google Scholar
• 17 LaForge K, Gold R, Cottrell E, Bunce AE, Proser M, Hollombe Cet al. How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview. J Ambul Care Manage. 2018;41(1):2–14. Crossref, Medline, Google Scholar
• 18 Stoto MA, Klaiman T, Davis M (Georgetown University; Washington, DC). A community health needs assessment environment scan [Internet]. Rochester (NY): SSRN; 2018 Nov 4 [cited 2020 Feb 11]. Available for download (account required) from: https://papers.ssrn.com/abstract=3230259 Google Scholar
• 19 Watson ER, Foster-Fishman PG. The Exchange Boundary Framework: understanding the evolution of power within collaborative decision-making settings. Am J Community Psychol. 2013;51(1–2):151–63. Google Scholar
• 20 Horne M. Values in social work. Second ed. London: Routledge; 1999. Google Scholar
• 21 Government Accountability Office. Federal low-income programs: eligibility and benefits differ for selected programs due to complex and varied rules [Internet]. Washington (DC): GAO; 2017 Jun [cited 2020 Feb 11]. (Report No. GAO-17-558). Available from: https://www.gao.gov/assets/690/685551.pdf Google Scholar
• 22 Brewster AL, Kunkel S, Straker J, Curry LA. Cross-sectoral partnerships by area agencies on aging: associations with health care use and spending. Health Aff (Millwood). 2018;37(1):15–21. Go to the article, Google Scholar
• 23 Schmit C, Kelly K, Bernstein J. Cross sector data sharing: necessity, challenge, and hope. J Law Med Ethics. 2019;47(2_suppl):83–6. Crossref, Medline, Google Scholar
• 24 Van Tulder R, Seitanidi MM, Crane A, Brammer S. Enhancing the impact of cross-sector partnerships: four impact loops for channeling partnership studies. J Bus Ethics. 2016;135(1):1–17. Crossref, Google Scholar
• 25 Catalyst for Payment Reform. Medicaid managed care contracts as instruments of payment reform: a compendium of contracting strategies [Internet]. Berkeley (CA): Catalyst for Payment Reform; [cited 2020 Feb 11]. Available from: https://www.catalyze.org/wp-content/uploads/woocommerce_uploads/2019/12/Medicaid-MCOs-as-Agents-of-Payment-Reform-1.pdf Google Scholar
• 26 Kushner J, McConnell KJ. Addressing social determinants of health through Medicaid: lessons from Oregon. J Health Polit Policy Law. 2019;44(6):919–35. Crossref, Medline, Google Scholar