Cross-sector Partnerships Research Articles

Overview of Singapore’s One Health Strategy

The One Health approach integrates human, animal, and environmental health to address complex challenges like emerging zoonotic diseases and antimicrobial resistance (AMR). Singapore’s dense urban environment, biodiversity, and role as a global hub make it vulnerable to these health threats, necessitating a robust and coordinated One Health framework. This paper reviews Singapore’s One Health strategy, focusing on governance, surveillance, cross-sector partnerships, and public health infrastructure. A structured literature review, including peer-reviewed articles and grey literature, identified key strengths and gaps. Strengths include interagency coordination through the One Health Coordinating Committee, advanced surveillance systems like CDLENS and SIDPIC, and key institutions such as the National Centre for Infectious Diseases (NCID) and the National Public Health Laboratory (NPHL). However, gaps remain in multi-sector engagement, data-sharing mechanisms, and public awareness of One Health principles. To address these challenges, this paper recommends enhancing multi-sector collaboration, strengthening data-sharing networks, and increasing public education on One Health. Investments in preventive medicine, cross-border capacity-building, and leveraging artificial intelligence for predictive analytics are essential for bolstering Singapore’s health security. By addressing these gaps, Singapore can enhance its preparedness and serve as a global leader in One Health implementation.

From trusted intruder to real collaborator: Mapping the ecosystem of stakeholders and community assets in a coastal region in England, with a focus on end-of-life care and bereavement support

While policy efforts to promote health through integration across sectors are not new, the 2022 UK Health and Care Act formalised Integrated Care Systems (ICSs) as legal entities with statutory powers in England. This includes a legal responsibility to commission adequate palliative and end-of-life care services, including bereavement support, for the communities they serve. Cross-sector partnerships that leverage community assets are recommended to tackle inequities towards the end of life and in bereavement. However, the nature of effective, equitable partnership remains unclear, and asset-based approaches have been criticised for neglecting issues of power and potentially transferring the responsibility for solving social and health injustices to communities. Aware of these debates, we critically explore the conditions that enable inclusive collaborative relationships and integration across sectors, as well as the barriers that prevent this, within the ecosystem of one coastal region in England. We conducted a system mapping study, drawing on theories of death systems, social capital, and service ecosystems, understood via Service-Dominant Logic (S-D L).Our three-phase participatory, qualitative study involved three community network meetings (attended by 35–55 stakeholders across sectors), a participatory digital mapping workshop (n = 19), and semi-structured interviews analysed using inductive thematic analysis (n = 15 stakeholders across sectors). Digital mapping showed weak or unstable bridging capital between sectors. Interviews highlighted that attending to the relational foundations of integration is essential but often omitted: opportunities and time to understand each other and co-create a shared vision, understanding differences and deepening connections, and, fundamentally, addressing power differentials. Failed attempts at generating bridging capital were linked to extractive relationships, widespread staff shortages and inadequate funding and resources, particularly in the VCSE. Understanding the nature of collaboration and social capital in a locality can support public health approaches which go beyond naïve calls for cross-sector collaboration to engender meaningful change.

Individual and organizational factors associated with public health workforce competencies to advance health equity.

Little is known about how to develop public health workforce capacity for health equity work. We explored associations of individual and organizational characteristics of local public health departments (LHDs) with competencies essential for advancing health equity. Data included responses of 29,751 staff from 742 LHDs in 48 states to the 2021 Public Health Workforce Interests and Needs Survey, plus LHD characteristics and county demographics. Logistic regression assessed associations between key factors and staff-reported "knowledge of" and "confidence in addressing" structural racism, health equity, social determinants of equity (SDoE), social determinants of health (SDOH), and environmental justice, as well as belief and involvement in addressing racism through one's work. Staff with a master's degree or higher compared to others had greater odds of reporting confidence in addressing structural racism (adjusted odds ratio [AOR] = 1.23) and health equity (AOR = 1.56), agreeing that addressing racism should be a part of their work (AOR = 2.45) and being involved in such efforts (AOR = 1.57). Staff identifying as Black, compared to white, had greater odds of reporting confidence in addressing all concepts: structural racism (AOR = 1.98), health equity (AOR = 1.34), SDoE (AOR = 1.53), SDOH (AOR = 1.21), and environmental justice (AOR = 1.72) and agreeing that addressing racism should be a part of their work (AOR = 2.11). Patterns were similar among staff identifying as Hispanic/Latino and other persons of color. Black (AOR = 0.68) and Hispanic/Latino (AOR = 0.83) staff had lower odds, however, of reporting engagement in activities to address racism. Finally, competencies positively associated with nearly all outcomes included cross-sector collaboration, ability to incorporate health equity into programming, and policy advocacy. LHD workforce development should include training that involves explicitly naming structural racism's effects and complementary skills, such as policy development and cross-sector partnership building. Further exploration is needed into how best to grow commitment among white staff and to support staff of color in health equity work.

UTILIZING COMMUNITY CONNECTIONS: A SOCIAL DETERMINANTS OF HEALTH SCREENING FOR COMMUNITY-DWELLING OLDER ADULTS

Abstract Community-based aging resources, like Area Agencies on Aging (AAA), are often underutilized. Establishing partnerships with healthcare providers can promote better awareness and use of available services/supports. We evaluated a community partnership between a primary care clinic and an AAA; both community partners were committed to reducing adverse health outcomes. This exploratory intervention study assessed social determinants of health (SDH) needs of Medicare-eligible primary care patients (n = 385) during an annual visit (Mage=72.5; 89.6% White) and connected patients to appropriate supportive aging services. There were 284 participants with identified unmet SDH needs, but only 36 participants accepted referral to AAA resources. We analyzed Medicare’s Risk Adjustment Factor (RAF) score at baseline and participants’ use of advanced care (i.e., ER visits/hospital readmissions/institutionalizations), urgent care, and primary care, over a 6-month period. Descriptive, bivariate, and multivariate analyses revealed positive associations between RAF score with age (p< 0.001) and number of SDH needs (p< 0.001), advanced care with SDH needs (p=0.004) and RAF score (p< 0.001), and primary care visits with SDH needs (p=0.003) and RAF score (p< 0.001). The screening revealed that older adults’ SDH needs are often unmet and underrecognized. Cross-sector partnerships between medical and social models of health can reduce risk and meet needs of community-dwelling older adults. Policy provisions that encourage such partnerships are needed to improve community-dwelling older adults’ wellbeing, independence, and ability to age-in-place.

Policy analysis of nutrition education programs in Indonesia: A literature study on the nutrition-conscious family program (Kadarzi)

Nutrition education is a crucial strategy to address the Triple Burden of Malnutrition in Indonesia, which encompasses undernutrition, overnutrition, and micronutrient deficiencies. This study aims to analyze the policies and implementation of the Nutrition-Conscious Family Program (Keluarga Sadar Gizi or Kadarzi) in Indonesia, focusing on identifying challenges and proposing improvements. Using a literature review methodology, this research evaluates the program's strengths, weaknesses, and effectiveness in promoting balanced nutrition behavior. Key findings indicate that while Kadarzi is effective in raising awareness about balanced nutrition, its implementation is hindered by inadequate health workers, limited funding, and insufficient cross-sectoral coordination. Furthermore, many activities remain undocumented, and uneven resource distribution affects the program's reach. Strategies for improvement include enhancing nutrition education, leveraging cross-sector partnerships, and increasing training for health cadres. The study concludes that tailored nutrition education programs, based on research and community needs, are essential for achieving better nutritional outcomes in Indonesia. Strengthening the Kadarzi program can significantly contribute to addressing persistent nutritional challenges and improving public health.

Reimagining autism research in the U.S.: A synergistic approach between social work, public health, and data analytics

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition that requires multifaceted research and interventions. This paper explores the synergistic potential of integrating social work, public health, and data analytics to address challenges in autism research and care in the United States. Social work emphasizes equitable access and community-based interventions, public health provides frameworks for addressing disparities and early detection, and data analytics introduces transformative tools for personalized care and longitudinal tracking. Despite progress in each domain, significant gaps remain, including disparities in diagnosis and fragmented systems of support. This paper proposes a synergistic framework for interdisciplinary collaboration, emphasizing cross-sector partnerships, centralized data sharing, community engagement, and scalable interventions. Policy and practice recommendations focus on enhancing access to services, building technological infrastructure, and promoting autism-friendly policies. By leveraging the strengths of these fields, this approach aims to improve outcomes for individuals with autism, fostering a more inclusive and effective system of care. Keywords: Autism Spectrum Disorder, Interdisciplinary Collaboration, Social Work, Public Health, Data Analytics, Early Intervention.

Cultivating Health in All Policies Mindsets: An Ongoing Journey to Integrate Health and Housing in Georgia.

This project report explores the use of a Health in All Policies (HiAP) approach by the Georgia Health Policy Center (GHPC) to integrate health perspectives into affordable housing policy and practice in Georgia. It focuses on five interconnected projects from over a decade-long collaboration to illustrate how the GHPC team started with a Health Impact Assessment (HIA) to seed cross-sector partnerships and then sustained them through subsequent collaborations. These projects included comprehensive-, intermediate-, and rapid-scale HIAs, as well as direct collaborations on housing development funding applications and a multidisciplinary research study on public housing renovations. This paper documents how HiAP tactics were applied across these projects to foster sustained collaboration and promote health equity. The insights offered highlight how the HiAP approach cultivated mindset shifts among public health practitioners, housing stakeholders, and policymakers, leading to a broader understanding of health and housing intersections. This synthesis contributes practical guidance for practitioners looking to advance the Vital Conditions for Health and Well-Being through housing policy initiatives.

Multi-Stakeholder Partnerships in the Development of Cultural Heritage Tourism in Binjai City

The cultural heritage buildings in Binjai City hold significant potential for cultural tourism, which can enhance the local economy and requires institutional support for development. Efforts to preserve cultural heritage while simultaneously improving the economic welfare of the community through tourism can be achieved through partnerships among involved stakeholders. Using a qualitative approach, this study analyzes the dynamics of partnerships between government, community members, business actors, academics, and the media in preserving and promoting the city’s cultural heritage. The findings indicate that multi-stakeholder partnerships are crucial for the successful development of cultural heritage tourism. Strong collaboration among various parties makes Binjai City's heritage sites attractive and sustainable tourism destinations. This research highlights the importance of cross-sector partnerships in cultural-based tourism development and provides policy recommendations for future development.

The Role of Health Systems in Cross-Sector Collaboration in Addressing Social Determinants of Health and Promoting Health and Well-Being.

The articles featured underscore the critical role of trust, strategic planning, and cross-sector partnerships in addressing health inequities, while emphasizing the need for further research on sustainable and cost-effective collaboration models. Tocco and colleagues from Northwell Health describe the formation of the Health Equity Taskforce (HET), initially aimed at equitable COVID-19 vaccine distribution on Long Island. The HET has since expanded to address broader health disparities, focusing on community involvement, strategic partnerships, and sustainability. Nemiroff and colleagues discuss collaborations with community partners and payors to address social determinants of health in underserved populations, highlighting opportunities that can facilitate collaborations such as the New York State's Medicaid 1115 Demonstration Waiver.

The Role of Health Systems in Cross-Sector Collaboration in Addressing Social Determinants of Health and Promoting Health and Well-Being.

The articles featured underscore the critical role of trust, strategic planning, and cross-sector partnerships in addressing health inequities, while emphasizing the need for further research on sustainable and cost-effective collaboration models. Tocco and colleagues from Northwell Health describe the formation of the Health Equity Taskforce (HET), initially aimed at equitable COVID-19 vaccine distribution on Long Island. The HET has since expanded to address broader health disparities, focusing on community involvement, strategic partnerships, and sustainability. Nemiroff and colleagues discuss collaborations with community partners and payors to address social determinants of health in underserved populations, highlighting opportunities that can facilitate collaborations such as the New York State's Medicaid 1115 Demonstration Waiver.

3.E. Scientific session: Environmental Health Tracking Systems: a tool for planetary health

Abstract Planetary health offers a good framework for better understanding the interconnection between human health and environmental changes, promoting effective cross-sector actions and partnerships, and ensuring policy coherence. Effective implementation of this conceptual framework requires monitoring and reporting on indicators relevant to planetary health that capture the scope, spatial and temporal scales of changes in natural systems that affect human health and well-being. An approach in that sense are the environmental public health tracking systems (EPHT), which imply the ongoing collection, integration, analysis, and interpretation of data at the same spatiotemporal scale about environmental hazards, and related human exposure and health effects, maintaining appropriate data protection measures. It aims to provide public-health decision makers with timely, accurate and systematic data for quantifying health impacts related to environmental factors. EPHT system are proposed as an essential tool for designing and monitoring policies and actions that prevent and reduce environmental health burdens (EHB) efficiently and cost-effectively, and as an alerting system against present and future climatic and health crisis. Pursuing such goals requires the use of health information systems that enable the monitoring and assessing of environmental health in multiple dimensions, considering specificities across different geographical and cultural settings. EPHT system requires defining a rationale on how to select the dimensions and indicators to be included. Common challenges for defining those indicators are related to the availability of data recording, data standardization, and the linkage, integration and sharing of databases. In parallel, it is also important to define a decision aiding tools in which evidence and data are understandable and inform about the extent to which specific policy goals are attained, tailoring such tools to the specific settings. Present session attends to answers to those challenges by sharing experiences from different contexts and countries Key messages • EPHT systems represent an effective tool for progressing in achieving planetary health goals and as a surveillance alerting system for future health crisis. • Adjusting EH data quality recording and analysis in EPHT systems is essential for improving resources assignment, and the effectiveness of healthy policies in reducing EHB.

Challenges and possibilities in adolescent loneliness interventions

Abstract Researchers typically associate the high prevalence of loneliness during adolescence with evolving dynamics and changes in relationships, both familial and peer-related. Consequently, transient feelings of loneliness are anticipated and considered part of the normative developmental process. While many adolescents naturally navigate through periods of loneliness by reconnecting with peers, a subset experiences prolonged feelings of loneliness. This group faces an increased risk of additional mental health issues and potential adverse health consequences. Such findings underscore the importance of effective and scalable interventions. This presentation draws upon a comprehensive meta-analytical review of loneliness interventions and a dedicated chapter in the upcoming Cambridge Handbook of Loneliness. focusing on interventions for adolescents. It will offer a brief overview of contemporary loneliness interventions and intervention strategies. Furthermore, it will discuss the unique considerations required when addressing loneliness in adolescents compared to other age groups. This includes the critical importance of loneliness prevention for adolescents, particularly within the school environment. Furthermore, the presentation will discuss the potential of community-based interventions aimed at tackling adolescent loneliness, showcasing the ongoing Danish community-based intervention ‘More Together.’ ‘More Together’ is a large-scale, complex, multi-component and multi-level intervention for community change that aims to reduce loneliness among young and elderly people. The intervention is rooted in an extensive cross-sector partnership. The presentation will highlight potentials and pitfalls encountered when addressing adolescent loneliness within a community setting.

Youth mental health outreach interventions: lessons from an experience capitalisation process

Abstract Issue Young people face socioeconomic, geographical and cultural barriers to access care and support in mental health. Practitioners implement outreach initiatives to improve mental health and address health inequalities, mostly developed in a ‘no-request for care’ context. Methods To better understand the implementation mechanisms of these initiatives, Fondation de France commissioned the French Society for Public Health to carry out an experience capitalisation to inspire other professionals. Experience capitalisation method was used, based on in depth interviews with project stakeholders. Covered themes were: the description of history, strategies and activities; identification of key moment and key levers; skills and knowledge used. Results Nine mental health outreach projects implemented across regions of France were selected with the help of a multidisciplinary steering committee. Each project was synthetised in a capitalisation document and a cross-sectional analysis was undertaken. Lessons • A variety of outreach approaches were carried on: meeting adolescents in the street or at coffee shops; home-based interventions; consultations in converted van etc. • Outreach is not just a matter of physically moving outside health structures but requires non-judging and flexible stance to adjust to the youth’s pace and will. To extend their approach to mobility, professionals deepen their team’s multidisciplinarity, broaden cross-sector partnerships and mobilise new skills and creativity. • Adolescents’ participation to care or support plans was one of projects strengths, whether they suffer from anxiety or mental disorders. However, their participation in governance and decisions regarding global projects remained limited. Key messages • To reduce mental health inequalities and enhance youth participation in outreach interventions, empowerment and wellbeing of interventions practitioners should also be supported. • Capitalisation of experience in health promotion is a promising method contributing to professional acknowledgment and development of shared knowledge on interventions implementation.

9.N. Practice session: From Data to Action – Joining forces to close the inequity gap in adolescent health

Abstract Persistent adolescent health inequalities exist in Europe, necessitating interventions that address both individual and societal factors, especially those pertinent to youths in unfavourable contexts. Collaborative efforts involving cross-sectoral partnerships and adolescent engagement are crucial in identifying and mitigating these disparities. Three case studies exemplify this approach. Case study 1: Effective intervention development hinges upon the translation of epidemiological insights into tangible actions. Heiko Schmengler will discuss how individual and contextual-level data is made actionable for the development of ePro-schools, an e-health intervention to promote healthy dietary habits and physical activity amongst adolescents in socially disadvantaged settings. ePro-schools brings together stakeholders from academia, the health sector, the education system, and local communities. This collaborative approach ensures that the intervention is not only grounded in solid scientific evidence but also fits the specific cultural, social, and economic contexts of the adolescents it aims to serve. Case study 2: Adolescents are not passive consumers of interventions, but active agents who frequently understand best what they need to improve regarding their health. Lourdes Cantarero Arevalo will share innovative methodologies and best practices for involving adolescents in data collection, intervention design, and policy development processes with the final aim to empower the voices of adolescents in vulnerable situations while addressing problems that are relevant for them. Case study 3: Filipa Alves da Costa will draw attention to the health concerns of adolescents resulting from incarceration. This talk will outline the development of a policy brief derived from UN global study data, which highlights the importance of cross-sectoral collaboration in developing actions to safeguard access to high quality healthcare for adolescents within the criminal justice system. A cross-sectoral approach is critical given that criminal justice systems typically fall outside the direct oversight of health ministries. The goal is to encourage policymakers, practitioners, and advocates to consider inter-sectoral strategies to address the complex health challenges these adolescents face. Following the presentations, we will facilitate a dynamic discussion with the audience, encouraging an exchange of ideas on strategies to address adolescent health inequalities from a multilevel perspective. This discussion aims to draw on the collective expertise of participants from diverse backgrounds, including practitioners, researchers, and policymakers. This dialogue aims to identify common barriers and opportunities, fostering a collaborative approach to tackling inequalities. The goal is to emerge from the workshop with a richer understanding of effective strategies that can be leveraged to close the gap in adolescent health across Europe. Key messages • Health inequalities among adolescents must be tackled collaboratively across different sectors and with participation of adolescents. • Participants will gain valuable insights on innovative solutions and effective methodologies from the case studies to inform their own efforts in addressing adolescent health inequalities.

Feasibility of a Community-Based Aquatic and Peer Support Intervention for People With Musculoskeletal Disorders Delivered via a Cross-Sector Partnership-A Service Evaluation.

Worldwide, the unmet rehabilitation needs of adults with musculoskeletal disorders are high. Aquatic exercise is clinically effective in managing musculoskeletal disorders, but access to rehabilitative services is limited. To determine the feasibility of a community-based aquatic exercise and peer support intervention for patients with musculoskeletal disorders delivered via a multisector partnership between an NHS physiotherapy service, a leisure operator and a social enterprise that creates personalised exercise programmes delivered through an application on a tablet computer. Cost-sharing was implemented after an initial complimentary session. A mixed method service evaluation was undertaken. Patient demographics, attendance, and patient-reported outcomes were summarised using descriptive statistics. Semi-structured interviews and an online survey were employed to explore patient acceptability of the intervention. Thirty four patients accessed the intervention during the 6-month pilot. Over half were from minority ethnic groups and nearly two thirds were in the bottom three deciles relating to low income. Patients exercised in a group of up to eight, supported by NHS rehabilitation professionals and volunteers. Provision of post-session refreshments encouraged connectivity between patients. Weekly attendance at the programme was high. Patient-reported outcome measures showed favourable changes in pain intensity and function following the intervention. Qualitative data suggest that the intervention was acceptable to patients. Implementation of a community-based aquatic exercise and peer support intervention for people with musculoskeletal disorders via a cross-sector partnership involving the NHS appears feasible and acceptable to patients. Further research is needed to assess the impact on musculoskeletal health and health inequalities.

Marketing-Driven Supply Chain Innovation: A Framework for FMCG SME Sustainability

In an increasingly competitive and sustainability-conscious market, small and medium-sized enterprises (SMEs) in the Fast-Moving Consumer Goods (FMCG) sector face unique challenges in achieving long-term sustainability. This review explores the concept of marketing-driven supply chain innovation as a strategic framework for enhancing SME sustainability. By integrating consumer-centric marketing strategies with supply chain operations, SMEs can align their product offerings, sourcing practices, and logistics with growing consumer demand for environmentally and socially responsible products. The framework outlined in this study includes key components such as sustainable product design, green logistics, ethical sourcing, and the incorporation of circular economy principles. Additionally, technology-driven innovation, such as data analytics and digital platforms, is emphasized as a tool to improve supply chain transparency, reduce waste, and optimize resource utilization. Through these collaborative efforts, SMEs can foster stronger consumer trust, enhance brand loyalty, and build a competitive edge in the market. Despite the potential benefits, the review also discusses the challenges SMEs may face, including limited financial resources, resistance to organizational change, and balancing profitability with sustainability goals. However, by leveraging green financing options, cross-sector partnerships, and phased implementation strategies, SMEs can overcome these barriers. Ultimately, the integration of marketing-driven supply chain innovation is positioned as a critical path for FMCG SMEs to achieve long-term sustainability, profitability, and market competitiveness in an evolving global economy. Keywords: Marketing-Driven, Supply Chain, FMCG SME, Review.

Do All Roads Lead to Rome? How Three Process Pathways Contribute to Transformative Innovation in Cross-Sector Partnerships

Do All Roads Lead to Rome? How Three Process Pathways Contribute to Transformative Innovation in Cross-Sector Partnerships

New Approaches for Sustainable Growth: Advancing Cross-sector Collaborations, New Capability Building, and Executive Leadership Development

Effective executive leadership is essential for the success and direction of any organization, regardless of the industry in which it operates. However, with today's interconnected economic production and distribution processes spanning complex networks operating in diverse geographic, social, and cultural markets, uncertainty has become more pronounced. In light of these changes, we propose a learning approach based on the Cross-Sector Partnership theory, which involves creating leadership collectives that work across sectors. These collectives can create innovative strategies for sustainable progress. We believe that universities can play a crucial role in fostering collaborations between different sectors, including industry and government. As hubs of knowledge creation, research, and talent development, universities are well-positioned to offer executive education programs, masterclasses, and professional development opportunities. Such initiatives can help create a culture of continuous learning and skill acquisition, which is vital for sustainable growth. By emphasizing the importance of cross-sector collaborations, we can build critical capabilities for sustainable progress and leverage executive leadership development as a powerful tool for achieving this goal.

Using social media to share universal messages about early language and literacy development with parents and caregivers

Purpose Health promotion and prevention interventions to support children’s early language and literacy development are essential, however little is known about how social media can be used in this context. This study evaluated an intervention which aimed to build capacity of parents in supporting children’s language and literacy skills, implemented using Facebook. Method A cross-sector partnership of Australian speech-language pathologists developed a suite of universal messages for parents to support their child’s language development. Messages were delivered across 12 weeks via Facebook. A convergent mixed methods study design was used to evaluate survey responses from parents of children aged 0–5 years, before (n = 136) and after the intervention (n = 61). Social media analytics were collected. Result Participants identified social media was a helpful way to receive information about supporting their child’s language and literacy development, reporting an increase in knowledge following the intervention. Participants reported they trusted information provided in Facebook posts as it was from professionals and evidence-based sources. The usability (i.e. look and layout) was generally rated highly. Conclusion Social media is a valuable tool for speech-language pathologists to deliver universal messages. Future social media initiatives should be co-designed with families and social media professionals to ensure delivery of trusted, consistent, and user-friendly information.

Identifying and addressing health-related social needs: a Medicaid member perspective.

Multiple state and national health care organizations have invested in activities to screen for and address the health-related social needs (HRSNs) of their patients. However, patient perspectives concerning HRSN screening discussions and facilitated referrals to supports are largely unexplored. The main objectives of this study were to explore the ways in which Massachusetts Medicaid (MassHealth) members engage with their health care clinicians to discuss HRSNs, to identify common needs discussed, and to describe whether members feel these needs are being addressed by health care clinicians and staff. The study team performed a cross-sectional, qualitative research study that included in-depth, open-ended interviews with 44 adult MassHealth members. Interviews were conducted between June and October 2022. Interviews were recorded, transcribed, and systematically coded for analysis, and common themes were reported. The data collected for this study were part of a larger independent evaluation of MassHealth's 2017-2022 Section 1115 Demonstration that granted authority from CMS to implement health care delivery system reforms in Massachusetts. In this qualitative study of Medicaid members, some reportedly felt comfortable freely discussing all of their clinical and social needs with their health care clinicians, while others noted feelings of apprehension. Several members recalled being asked about their HRSNs in various clinical or community settings, while others did not. The majority of members endorsed having an unmet HRSN, including housing, nutrition, financial, or transportation issues, and many barriers to addressing these HRSNs were discussed. Finally, many members cited a preference for discussing HRSNs with community-based care coordinators and social workers at the community partner organizations rather than with their health care clinicians. Community-based care coordinators were lauded as essential facilitators in making the connection to necessary resources to help address HRSNs. Study results highlight an opportunity to increase the effectiveness of HRSN screening and referral practices within the health care setting through relationship building between Medicaid members and diverse interdisciplinary care teams that include staff such as community health workers. Continued investment in cross-sector partnerships, screening workflows, and patient-clinician relationships may contribute to establishing an environment in which members can comfortably discuss HRSNs and connect with needed services to improve their health.