Integrating Social Services With Primary & Behavioral Health Care

Research underscores the positive impact of integrated primary care and behavioral health delivered by interprofessional teams of medical and mental health professionals. Studies also suggest that integrating health and human services to address health-related social needs (HRSN) can improve health outcomes and reduce health disparities among some populations, including individuals with complex chronic health conditions.

Providers can begin by conducting routine screening for social determinants of health (SDOH) and associated HRSN using a screening tool. Examples of adverse outcomes related to SDOH include asthma exacerbations triggered by poor housing conditions, diabetes-related hospital admissions related to food insecurity, lack of prenatal care due to transportation barriers, and stress-related illness resulting from unemployment.

Integrating frontline peer support and community health workers into your care team, referring patients to local social service providers, and partnering with community-based organizations are among the possible ways to provide needed supports to address HRSN as part of a person-centered care plan. Enlisting behavioral health workers and community-based resources can also increase patient and family engagement, strengthen patient self-management, and reduce the burden on healthcare providers.

Delivering integrated care that addresses patients’ physical, behavioral, and social needs may require changes in how providers organize and deliver services. As DC Medicaid managed care plans increasingly adopt value-based payment programs in their contracts with primary care and behavioral health providers to incentivize quality care, finding ways to integrate social services with primary and behavioral health care will be critical for ensuring whole-person care.

For example, The Ark of DC, a freestanding mental health clinic, is working with coaches from Integrated Care DC to integrate HRSN screening into its workflows for intake assessment and treatment planning. The organization trained its staff to screen all patients using the standardized Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE®) screening tool and is now working on developing enhanced referral relationships with SDOH providers to ensure effective linkages to care.

Like The Ark of DC, you can take the next step in transforming your practice. Sign up today for a consultation with an Integrated Care DC coach or email us at to discuss how we can help. We also encourage you to view our resources on Forming Strategic Partnership Agreements and Care Compacts and Integrated Care DC Provider Information Session to find valuable training and tools that can benefit your practice.