Aligning social and health care services: The case of Community Care Connections

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

Research output: Contribution to journalArticlepeer-review


The Community Care Connections (CCC) program aims to align social and healthcare services to improve health outcomes in older adults with complex medical and social needs. This study assessed changes in healthcare utilization before and after CCC program participation. Between June 2016 and March 2019, 1214 adults with complete data who provided informed consent participated in the CCC program. CCC client data were linked with data on hospitalizations, emergency department (ED) visits, and observation stays 90 days before and after program start. Data analysis examined changes in health care utilization 90 days after program start, compared to 90 days before. Hospitalizations decreased by 30% (Change = −0.029, 95% Confidence Interval (CI) = −0.053, −0.005), ED visits decreased by 29% (Change = −0.114, 95% CI = -0.163, −0.066), and observation stays decreased by 23% (Change = −0.041, 95% CI = -0.073, −0.009) during the post period. ED visits decreased by 37% (Change = −0.140, 95% CI = -0.209, −0.070) for those with hypertension and by 30% (Change = −0.109, 95% CI = -0.199, −0.020) for those with high cholesterol, while observation stays decreased by 46% (Change = −0.118, 95% CI = -0.185, −0.052) for those with diabetes and by 44% (Change = −0.082, 95% CI = -0.150, −0.014) for those with high cholesterol during the post period. Connecting older adults with social services through the healthcare delivery system may lead to decreases in hospitalizations, ED visits, and observation stays. Implementation of cross-sector partnerships that address non-clinical factors that impact the health of older adults may reduce the use of costly healthcare services.

Original languageEnglish (US)
Article number106350
JournalPreventive Medicine
StatePublished - Feb 2021


  • Aging services
  • Healthcare utilization
  • Population health
  • Program evaluation
  • Social determinants
  • Social services

ASJC Scopus subject areas

  • Epidemiology
  • Public Health, Environmental and Occupational Health


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