Aligning Health Care and Social Services to Reduce Hospitalizations and Emergency Department Visits: An Evaluation of the Community Care Connections Program

Kelley Akiya, Elisa Fisher, Annie Wells, Yan Li, Christine Peck, José A. Pagán

Research output: Contribution to journalArticlepeer-review


Background: Integration of social services in health care delivery is increasingly recognized as a potential strategy for improving health and reducing the use of acute care services. Collaborative models that provide older adults with case management, linkages to social services, and assistance with health care navigation have emerged as promising strategies. Objective: The objective of this study was to evaluate the Community Care Connections (CCC) program, a cross-sector collaboration designed to align social and health care services for older adults. Research Design: We compared hospitalizations and emergency department (ED) visits 90 days after enrollment with a propensity score-matched group of non-CCC patients. Subgroup analyses were also conducted for adults with hypertension, diabetes, and high cholesterol. Subjects: A total of 1004 patients enrolled in CCC between June 1, 2016, and November 15, 2018, and 1004 matched patients from the same metropolitan area. Measures: Mean hospitalizations and ED visits per patient 90 days after CCC enrollment. Results: Mean hospitalizations were lower among CCC patients 90 days after enrollment than among non-CCC adults [difference=-0.039, 95% confidence interval (CI): -0.077 to -0.001, P=0.044]. They were also lower among CCC patients with hypertension (difference=-0.057, 95% CI: -0.103 to -0.010, P=0.017). However, 90 days after enrollment mean ED visits were higher among CCC patients relative to non-CCC adults (difference=0.238, 95% CI: 0.195-0.281, P<0.001). Conclusions: Connecting older adults to social services while being served by the health care system may lead to decreases in hospitalizations. Cross-sector partnerships that address social and economic needs may reduce the use of costly health care services.

Original languageEnglish (US)
Pages (from-to)671-678
Number of pages8
JournalMedical care
Issue number8
StatePublished - Aug 2021


  • care coordination
  • health care navigation
  • hospitalizations
  • hypertension
  • social services integration
  • Hypertension
  • New York
  • Humans
  • Middle Aged
  • Male
  • Diabetes Mellitus
  • Community Health Services/organization & administration
  • Hypercholesterolemia
  • Case Management
  • Aged, 80 and over
  • Female
  • Hospitalization/statistics & numerical data
  • Social Work/organization & administration
  • Aged
  • Emergency Service, Hospital/statistics & numerical data

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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