Public Access Records Office
The National Academies
500 5th Street NW
Room KECK 219
Washington, DC 20001
Tel: (202) 334-3543
Project Information

Project Information

Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation's Health

Project Scope:

An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will be developed to examine the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes and to address major challenges facing the U.S. health care system.  These challenges, include persisting disparities in health outcomes among vulnerable subpopulations, often defined by age, race, ethnicity, sex, gender identity, disability status, sexual orientation, socioeconomic status, family caregiver status, immigrant status, and geographic location. The committee will discuss: 1) approaches currently being taken by health care providers and systems, and new or emerging approaches and opportunities; 2) current roles of different disciplines and organizations, and new or emerging roles and types of providers; and 3) current and emerging efforts to inform the design of an effective and efficient care system that improves the nation's health and reduces health inequities. In creating its report, the committee will consider the:

1.     Current scope and conceptual underpinnings of health-related social needs care, including: a) roles of providers such as social workers, gerontologists, physicians, psychologists, nurses, community health workers, and trained volunteers; b) linkage to community-based organizations and services; and c) the role of hospital community benefits. 

2.     Current state of the social needs care workforce in preventing, controlling, and treating health-related conditions (e.g., disciplines providing social needs care and their professional qualifications, breadth of settings, and roles for such care, including administrative, policy, and research roles; current training for each discipline related to provision of social needs care; and projected workforce needs to meet demographic changes).

3.     Evidence of impact of social needs care on patient and caregiver/family health and well- being, patient activation, health care utilization, cost savings, and patient and provider satisfaction.

4.     Opportunities and barriers to expanding historical roles and leadership of social workers in providing health-related social needs care, and the expanding role of other types of providers, such as gerontologists.

5.     Emerging and evidence-based care models that incorporate social workers and/or other social needs care providers in interprofessional care teams across the care continuum (e.g., acute, ambulatory, community-based, long-term care, hospice care, public health, care planning) and in delivery system reform efforts (e.g., enhancing prevention and functional status, care management, and transitional care; improving end-of-life care; integration of behavioral, mental, and physical health services).

6.     Initiatives to improve population health and reform health care financing that incorporate social needs care (i.e., payments tied to quality metrics and alternative payment models, such as Accountable Care Organizations, bundled payments, managed long-term services and supports, and Accountable Health Communities).

7.     Realized and potential contributions of social needs care to make health care delivery systems more community based, person- and family/caregiver-centered, and responsive to social and structural determinants of health, particularly for vulnerable populations and communities, such as older adults and low-income families.

8.     Opportunities for advancing the integration of social needs care services within community and health care delivery settings, such as expanding and improving interprofessional education, educating health care providers, payers, and patients about the benefits of social needs care services, and ensuring adequate reimbursement by public and private payers.

9.     Kinds of transdisciplinary research needed to understand the complex interplay of psychosocial and environmental factors on health, and best to inform efforts to develop policies and practices that lead to improved health outcomes.

The committee will make recommendations on how to: 1) expand social needs care services; 2) better coordinate roles for social needs care providers in interprofessional care teams across the continuum of clinical and community health settings; and 3) optimize the effectiveness of social services to improve health and health care. Recommendations may address areas such as integration of services, training and oversight, workforce recruitment and retention, quality improvement, research and dissemination, and governmental and institutional policy for health care delivery and financing.

Status: Current

PIN: HMD-HCS-16-09

Project Duration (months): 18 month(s)

RSO: Mitchell, Abigail


Board on Health Care Services


Behavioral and Social Sciences
Health and Medicine

Committee Membership

Committee Post Date: 07/18/2018

Dr. Kirsten Bibbins-Domingo - (Chair)
Kirsten Bibbins-Domingo, Ph.D., M.D., M.A.S., is Lee Goldman, MD Endowed Chair in Medicine, Professor and Chair of the Department of Epidemiology and Biostatistics, and Professor of Medicine at the University of California, San Francisco (UCSF). She is the inaugural Vice Dean for Population Health and Health Equity in the UCSF School of Medicine. Dr. Bibbins-Domingo co-founded and directs the UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, a research center focused on discovery and implementation science in clinical, community, and policy arenas aimed at improving the health of vulnerable populations. Dr. Bibbins-Domingo is a practicing general internist at Zuckerberg San Francisco General Hospital and has expertise in cardiovascular disease, hypertension, and diabetes, with a particular interest in the development of these conditions in young adults. Her research focuses on identifying effective clinical, public health, and policy interventions aimed at prevention and management of these chronic conditions. Dr. Bibbins-Domingo has been inducted into the American Society for Clinical Investigation and the Association of American Physicians. She is a member of the National Academy of Medicine, and has served as a member of several consensus committees of the National Academies of Sciences, Engineering, and Medicine, including the 2014 committee “Capturing Social and Behavioral Domains and Measures in Electronic Health Records.” She was a member of the US Preventive Services Task Force from 2010-2017 and led the Task Force as the vice-chair and chair from 2014-2017.

Dr. Toyin Ajayi
Toyin Ajayi, M.D., M.Phil., is the Chief Health Officer at Cityblock, a New York-based company that delivers integrated primary care, behavioral health and social services to qualifying Medicaid or Medicare members who live in city neighborhoods that have traditionally gone without good health services. Prior to Cityblock, Dr. Ajayi served as Chief Medical Officer of Commonwealth Care Alliance, a Massachusetts not-for-profit health plan serving individuals dually-eligible for Medicare and Medicaid. In this role, she led all clinical operations; spearheaded care delivery innovations; and oversaw multi-disciplinary teams of more than 500 clinicians, community health workers, and administrators, serving more than 20,000 beneficiaries. Dr. Ajayi is a board-certified family physician and continues to practice primary care and hospital medicine focused on patients with chronic, complex, and end-of-life needs. Internationally recognized as a leader in care for populations with complex needs, Toyin has been published in the New England Journal of Medicine and Health Affairs, is an NEJM Catalyst "thought leader", and has advised organizations such as the Robert Wood Johnson Foundation, the Commonwealth Fund, and the Institute for Healthcare Improvement.
Dr. Tamara Cadet
Tamara J. Cadet, Ph.D., M.S.W., M.P.H., is assistant professor at the Simmons College School of Social Work. She also holds a faculty appointment at the Harvard School of Dental Medicine in Oral Health Policy and Epidemiology. Dr. Cadet brings her more than 25 years of practice experience in many capacities and settings to her teaching and to her research. Dr. Cadet has worked in the fields of substance abuse, adoption, mental health, health care, schools, and oncology with children, adults, families, and older adults, as both a social worker and as a community organizer. Her ultimate objective is to advance efforts to develop health promotion interventions for underserved and underrepresented older adults in order to contribute to reducing oncology-related disparities. To this end, her research has primarily focused on improving access to cancer prevention, early detection, and treatment services for older minority adults.
Dr. Lisa A. Cooper
Lisa Cooper, M.D., M.P.H., is a board-certified general internist, the James F. Fries Professor of Medicine, and a Johns Hopkins University Bloomberg Distinguished Professor, holding primary appointments in the Johns Hopkins University School of Medicine and Bloomberg School of Public Health, and a joint appointment in the Johns Hopkins School of Nursing. Trained as a social epidemiologist and health services researcher, Dr. Cooper was one of the first scientists to document disparities in the quality of relationships between physicians and patients from socially at-risk groups. She then designed innovative interventions targeting physicians’ communication skills, patients’ self-management skills, and healthcare organizations’ ability to address social determinants of health in populations experiencing health disparities Currently, Dr. Cooper directs The Johns Hopkins Center for Health Equity, where she and her transdisciplinary team work with stakeholders from healthcare and the community to implement rigorous clinical trials, identifying interventions that alleviate racial and income disparities in social determinants and health outcomes. The Center also provides training to a new generation of health equity scholars and advocates for social change with policymakers. Dr. Cooper is a member of the National Academy of Medicine and has received numerous awards for her pioneering research, including a prestigious MacArthur “Genius Grant” Fellowship.
Dr. Karen B. DeSalvo
Karen DeSalvo, M.D., M.P.H., M.Sc., is professor of Medicine and secondary appointment in the Department of Population Health at the University of Texas at Austin Dell Medical School. She provides leadership on a range of projects across the mission of the medical school and that take advantage of the cutting-edge work happening on the University of Texas campus in the areas of community health, medical care and research related to the social determinants of health. She looks for ways to leverage technology and digital health in traditional public health programs and strategies — both to advance health beyond the traditional medical model and to address issues where people live, learn, work and play. From 2014 to 2016 DeSalvo served as the National Coordinator for Health Information Technology, a role in which she was responsible for setting national strategy and policy on health IT. She also concurrently served as the Acting Assistant Secretary of Health from 2014 until 2017. Prior to that, Dr. DeSalvo served as New Orleans Health Commissioner and Professor of Medicine and Vice Dean for Community Affairs and Health Policy at the Tulane University School of Medicine. Dr. DeSalvo is a member of the National Academy of Medicine and recently served on the NASEM Roundtable on Population Health Improvement.
Dr. Chris Esguerra
Chris Esguerra, M.D., M.B.A., is Division Vice President and Senior Medical Director at Care1st Health Plan, an affiliate of Blue Shield of California. He has worked in health care provider and systems leadership, managed care, case management, utilization management, quality, and pharmacy. His work also addressed health care and health plan operations alongside compliance with Medicare, Medi-Cal, and Knox Keene lines of business. He has led significant efforts around integration of care, addressing social determinants of health, and helping people remain and age in the community with appropriate long terms services and supports. Dr. Esguerra led the primary and behavioral health care integration work at San Mateo County Behavioral Health and Recovery Services called Total Wellness, addressing not only primary and behavioral health care for those with serious mental illness, but also establishing peer supports, addressing nutrition, enhancing social connectedness, and improving physical activity in this cohort. At Health Plan of San Mateo, he facilitated the effort to transition institutionalized members into the community with a combination of intensive case management, housing services and support, government services support, and community based services. This effort included addressing nutrition, housing, social connectedness, independent living skills support, in home support services needs, and promoting self-management in addition to strong primary care supported by strong care coordination. He has helped provider organizations enhance their care delivery strategy and shaped strategic growth. He has also helped other organizations evolve their capabilities in identifying social determinants of health as they interact with physical and behavioral health conditions to better target and improve services and interventions. Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association.
Dr. Janet C. Frank
Janet C. Frank, DrPH, MS in Gerontology, BSW, is a faculty associate at the UCLA Center for Health Policy Research and an adjunct associate professor in Community Health Sciences at the UCLA Fielding School of Public Health. From 1990 to 2013, she served as Assistant Director of Academic Programs in the UCLA Multicampus Program in Geriatric Medicine and Gerontology at the Geffen School of Medicine at UCLA. In that role, she designed and directed a number of successful grant-funded projects, including the California Geriatric Education Center, an interdisciplinary statewide training center funded by the Health Resources and Services Administration; the Skills for Healthy Aging Resources and Programs (SHARP) a career technical education program for evidence-based programs, funded by the U.S. Department of Education; and the National Coordinating Center for the Resource Centers for Minority Aging Research, funded by the National Institute of Aging. Currently, she is Principal Investigator for the Older Adult Mental Health Services: Future Recommendation for Workforce Education and Training project funded by Archstone Foundation; founder of Applied Aging Resources, a consulting business; and a co-investigator for the NIH Diversity Program Consortia Coordination and Evaluation Center. As Principal Investigator, she recently completed the California Mental Health Older Adult System of Care Project, the first study of the impact of the Mental Health Service Act on older adult mental health.
Dr. Rachel Gold
Rachel Gold, Ph.D., M.P.H., is an Investigator at the Kaiser Permanente Northwest Center for Health Research, with a joint appointment at the OCHIN community health information network, where she is the Lead Research Scientist. Dr. Gold’s work centers on OCHIN’s national network of safety net clinics. Her research assesses how electronic health records (EHRs) and other health information technology tools can be used to reduce health disparities. One line of inquiry asks how to improve rates of guideline-concordant primary care in the safety net setting, with a focus on optimizing the implementation of evidence-based clinical decision support tools. Another asks how to help community health centers collect and act on information about patients’ social determinants of health, using EHR-based documentation and referral tools. Dr. Gold also serves on several national committees focused on social needs intervention research.
Ms. Robyn Golden
Robyn Golden, L.C.S.W., is the Associate Vice President of Population Health and Aging at Rush University Medical Center in Chicago, where she also holds academic appointments in the Departments of Medicine, Nursing, Psychiatry and Health Systems Management. She is responsible for developing and overseeing health promotion and disease prevention, mental health, care coordination and transitional care services for older adults, family caregivers and people with chronic conditions. Golden is key to the development of interprofessional models of care for Rush’s population health programs. She is currently the principal investigator for the HRSA Funded Geriatric Workforce Enhancement Program and the Commonwealth Funded Primary Care Redesign Project. For over 30 years, Golden has been actively involved in service provision, program development, education, research and public policy aimed at developing innovative initiatives and systems integration to improve the health and well-being of older adults and their families.
Dr. Laura Gottlieb
Laura Gottlieb, M.D., M.P.H., is associate professor of Family and Community Medicine at UCSF. A former National Health Services Scholar and safety-net family physician with fellowship training in social determinants of health, Dr. Gottlieb now serves as Principal Investigator on multiple quantitative and qualitative projects examining the integration of social and medical care services. These projects range from large randomized trials on specific interventions undertaken in clinical settings to projects that explore the scope of this rapidly evolving field, including by characterizing the payment, technology, and workforce foundation for care integration. She is the founding director of the Social Interventions Research and Evaluation Network (SIREN), a national research acceleration and translation institute that brings together researchers across the United States to synthesize, disseminate, and catalyze research at the intersection of social and medical care. Dr. Gottlieb also is Associate Director of the Robert Wood Johnson National Program Office Evidence for Action grants program based at the UCSF Center for Health and Community.
Dr. Sean Joe
Sean Joe, Ph.D., M.S.W., is the Benjamin E. Youngdahl Professor of Social Development and Associate Dean for Faculty and Research at Brown School at Washington University in St. Louis. Dr. Joe is a nationally recognized authority on suicidal behavior among African Americans. His research focuses on Black adolescents’ mental health service use patterns, the role of religion in Black suicidal behavior, salivary biomarkers for suicidal behavior, and development of father-focused, family-based interventions to prevent urban African American adolescent males from engaging in multiple forms of self-destructive behaviors. Working within the Center for Social Development, Dr. Joe launched the Race and Opportunity Lab, which examines race, opportunity, and social mobility in the St. Louis region, working to reduce inequality in adolescents’ transition into adulthood.
Mr. Christopher F. Koller
Christopher Koller is President of the Milbank Memorial Fund. Before joining the Fund, he served the state of Rhode Island as the country’s first health insurance commissioner, an appointment he held from March of 2005 through June of 2013. Under Mr. Koller’s leadership, the R.I. Office of the Health Insurance Commissioner used its rate review process and insurance regulation to promote payment reform, primary care revitalization, and delivery system transformation. The Office was also one of the lead agencies in implementing the Affordable Care Act in Rhode Island. Prior to serving as health insurance commissioner, Mr. Koller was the CEO of Neighborhood Health Plan of Rhode Island for nine years. In this role he was the founding chair of the Association of Community Affiliated Plans. He is a member of the NASEM Board on Health Care Services and was a member of the IOM Committee on Determination of Essential Health Benefits. He serves in numerous national and state health policy advisory capacities. Mr. Koller is also an adjunct professor of community health in the School of Public Health at Brown University.
Ms. Cindy Mann
Cindy Mann, J.D., is partner at Manatt Health in Washington, DC. Her work on behalf of states, health systems, foundations and consumer groups focuses on developing and implementing strategies around federal and state health reform, Medicaid, the Children’s Health Insurance Program (CHIP), and delivery and payment system transformation. Before joining Manatt, Ms. Mann was with the Centers for Medicare & Medicaid Services (CMS). There, she served as deputy administrator and director of the Center for Medicaid and CHIP Services. She led the administration of Medicaid, CHIP, and the Basic Health Program for more than five years during the implementation of the Affordable Care Act. She set federal policy, supported state program operations, and coordinated policy and program operations with the marketplace, as well as broader delivery system and payment system reform. Prior to working at CMS, she was a research professor at the Georgetown University Health Policy Institute and co-founder of the Center for Children and Families., a senior advisor at the Kaiser Commission on Medicaid and the Uninsured, and director of the Family and Children’s Health Program group at the Health Care Financing Administration (HCFA), now CMS. Ms. Mann joined the HCFA from the Center on Budget and Public Policy, where she directed the center’s federal and state health policy work.
Dr. Diana J. Mason
Diana Mason, Ph.D., R.N., FAAN, is the Senior Policy Service Professor at the Center for Health Policy and Media Engagement, George Washington University School of Nursing. She is professor emerita at Hunter College, City University of New York, where she was the inaugural Rudin Professor of Nursing and co-founder and co-director of a Center for Health, Media & Policy until 2016. Dr. Mason is the immediate past president of the American Academy of Nursing, former editor-in- chief of the American Journal of Nursing, and co-producer and moderator of a weekly radio program on health care issues since 1985. She is the lead editor of the book, Policy and Politics in Nursing and Health Care and the author of over 200 publications. Her scholarship focuses on health policy and what can be learned from nurse-designed models of care. With funding from the Robert Wood Johnson Foundation and in collaboration with the RAND Corporation, Dr. Mason was co-principal investigator for a study to explore how nurses address building a culture of health in their innovative models of care. She is a member of the board of directors for the Primary Care Development Corporation and Public Health Solutions, and of the National Advisory Committee for Kaiser Health News.
Dr. Kedar Mate
Kedar Mate, M.D., is the Chief Innovation and Education Officer at the Institute for Healthcare Improvement (IHI) and a faculty member at Weill Cornell Medical College. Dr. Mate’s scholarly work has focused on health system design, health care quality, strategies for achieving large-scale change, and approaches to improving value. He is the recipient of the Paul & Daisy Soros Fellowship and has been recognized as an Aspen Institute Healthcare Innovator. Previously Dr. Mate worked at Partners In Health, served as a special assistant to the Director of the HIV/AIDS Department at the World Health Organization, and led IHI’s national program in South Africa. Dr. Mate has published numerous peer-reviewed articles, book chapters, and white papers. He served on the NASEM Planning Committee for a Workshop on Improving Quality of Care in Low-and Middle-Income Countries.
Mr. Edward Salsberg
Edward Salsberg, M.P.A., FAAN, is Director of Health Workforce Studies at the George Washington University Health Workforce Institute and research Faculty at the George Washington University School of Nursing. Mr. Salsberg has been a national leader in health workforce research, policies, and data for over 25 years. He established and managed three health workforce research centers. He has authored and co-authored numerous reports and papers on the health workforce. Prior to joining George Washington University, Mr. Salsberg was the founding director of the National Center for Health Workforce Analysis in the US Department of Health and Human Services, which was authorized by Affordable Care Act. He previously established and directed the Center for Workforce Studies at the Association of American Medical Colleges (AAMC) and the Center for Health Workforce Studies at the School of Public Health at the University at Albany of the State University of New York. All three health workforce centers have been leaders in providing information on the supply, demand, distribution, and use of the health care workforce and they have pioneered approaches to collecting health workforce data. From 1984 until 1996, Mr. Salsberg was a Bureau Director at the New York State Department of Health. Mr. Salsberg is currently leading a multi-year study of the social work workforce. He has participated in several NASEM activities, including serving as a member of the Committee on Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report the Future of Nursing and on the planning committee for a Workshop on Graduate Medical Education Outcomes and Metrics.
Dr. Elizabeth C. Tilson
Elizabeth Cuervo Tilson, M.D., M.P.H., is the State Health Director and the Chief Medical Officer for the North Carolina Department of Health and Human Services. In this role, she promotes public health and prevention activities and provides guidance and oversight on a variety of cross-departmental issues. As part of her work, she provides leadership for North Carolina’s statewide multi-prong approach to addressing social determinants of health and connecting health care and social service systems. She is also a practicing physician and delivers primary care at the Wake County Human Services Child Health Clinic. Before joining NC DHHS, Tilson was the Medical Director of Community Care of Wake and Johnston Counties, one of the 14 Community Care of North Carolina (CCNC) networks, and the Chief Network Clinical Officer for CCNC. In that role, she worked to support local multi-sector systems of care and promote innovative strategies to improve the coordination of care for high-risk patients with chronic illness. Prior roles have also included serving as an Assistant Consulting Professor and Cancer Control Specialist with Duke University Medical Center and a Clinical Pediatric Fellow at the University of North Carolina at Chapel Hill. She is board certified in Pediatrics and General Preventive Medicine/Public Health.
Ms. Keegan Warren-Clem
Keegan D. Warren-Clem, J.D., L.L.M., is the founding director of Austin Medical-Legal Partnership (MLP) and is adjunct professor at The University of Texas School of Law. Through Austin MLP she works collaboratively with healthcare providers in the clinical setting to improve health outcomes through legal assistance for patients and legal education for both patients and providers. Keegan also challenges law, medical, and other health students as well as pediatric residents to explore connections between health, poverty, and unmet legal needs. Complementing recent publications on public health law and policy, and the use of population health norms to understand outcomes of legal interventions, Keegan’s current research includes collaborative clinical policy-making in the wake of natural disaster.

Committee Membership Roster Comments

Dr. Janet Frank has been added as a member of the committee.



Keck Center
500 5th St NW, Washington, DC 20001
Event Type :  

Registration for Online Attendance :   

Registration for in Person Attendance :   

If you would like to attend the sessions of this event that are open to the public or need more information please contact

Contact Name:  Annalee Gonzales
Contact Email:
Contact Phone:  (202) 334-2001

Is it a Closed Session Event?
Some sessions are open and some sessions are closed


Keck Center
500 5th St NW, Washington, DC 20001
Event Type :  

Registration for Online Attendance :   

Registration for in Person Attendance :   

If you would like to attend the sessions of this event that are open to the public or need more information please contact

Contact Name:  Annalee Gonzales
Contact Email:
Contact Phone:  (202) 334-2001

Please register for the open session from the following webpage:

July 16, 2018
1:00 pm to 5:00 pm EDT
Keck Center of the National Academies, Room 208
500 Fifth Street, NW
Washington, DC 20001

Welcome and introductory remarks, Kirsten Bibbins-Domingo, Committee Chair

Invited presentations (15-min each):
-Robert Wood Johnson Foundation, Susan Mende, Senior Program Officer (via webconference)
-Archstone Foundation, Jolene Fassbinder, Program Officer
-Center for Innovation in Social Work and Health, Boston University School of Social Work, Sara Bachman, Director
-Council on Social Work Education, Darla Spence Coffey, President and Chief Executive Officer
-Kaiser Permanente National Community Benefit, Loel Solomon, Vice President for Community Health (via webconference)
-National Association of Social Workers, Angelo McClain, Chief Executive Officer
-New York Community Trust, Natasha Lifton, Senior Program Officer, Promising Futures/Human Services (via webconference)

Brief comments from other sponsors of the study and from members of the public

Open discussion about the study and the statement of task
Is it a Closed Session Event?

Closed Session Summary Posted After the Event

The following committee members were present at the closed sessions of the event:

Kirsten Bibbins-Domingo (Chair)
Toyin Ajayi
Tamara Cadet
Lisa Cooper
Karen DeSalvo (via phone)
Chris Esguerra
Janet Frank
Rachel Gold (via phone)
Robyn Golden
Laura Gottlieb (via phone)
Sean Joe
Christopher Koller
Cindy Mann
Diana Mason
Kedar Mate
Edward Salsberg
Elizabeth Cuervo Tilson
Keegan Warren-Clem

The following topics were discussed in the closed sessions:

-Potential sources of bias and conflicts of interest
-Committee composition
-Project schedule
-Statement of task
-Approach to addressing the statement of task
-Draft report outline
-Literature search strategy
-Committee assignments for evaluating the evidence
-Potential topics and speakers for a future public session
-National Academy of Medicine's Culture of Health Program

The following materials (written documents) were made available to the committee in the closed sessions:

-Meeting agenda
-Committee/staff roster
-Project schedule
-Statement of task
-List of sponsors and statement from sponsors
-Draft report outline
-Literature search strategy
-NASEM definitions of finding, conclusions, and recommendations, and guidelines for recommendations


  • Publications having no URL can be seen at the Public Access Records Office

No data present.