Organizational Risk in Multi-Sector Health Partnerships: a Case Study of Oregon\u27s Accountable Health Communities

The literature on collective action has documented that the perception of organizational risk -- both the uncertainty of potential outcomes and the meaning attached to them -- is an important factor in whether and how organizations engage in cross-sector collaborations. Yet there are few examples to date that document how health and social service leaders perceive organizational risks in cross-sector health partnerships focused on social determinants of health, or how their perceptions influence organizational commitment and willingness to engage in these partnerships over time. This research aimed to fill this gap through a mixed methods case study of health and social service organizations in four suburban and rural communities in Oregon that were engaged in the Center for Medicare and Medicaid Services\u27 Accountable Health Communities (AHC) initiative in 2019. Initiatives such as AHC are intended to overcome the challenges of coordinating the delivery of health care and social services by implementing new processes for systematically identifying patients\u27 unmet social needs, connecting patients with appropriate community resources, and leveraging care coordination technology to monitor these efforts over time. Interviews and surveys were conducted with organizational leaders at primary care, public health, and dental care organizations participating in patient screening, referral and navigation activities for unmet social needs. Patient referrals data were used to identify and recruit social service organizations that had received patient referrals through AHC; these included community-based and faith-based social service agencies, affordable housing organizations, and emergency food and shelter programs. Interviews and surveys were thematically analyzed to explore and compare how organizational leaders perceived the risks of cross-sector partnerships, and how these risks varied across organization and sector lines. This research found that health and social service leaders described different constraints and resource dependencies and held different views on whether and how multi-sector collaboration advanced their organizational interests. Health and social service organizations operated within different sociopolitical contexts and were highly adapted to specific service populations, issues and funding streams that were narrowly defined within various federal health and human services policy. Misalignment of these categorical distinctions at the federal level created perceived risks in multi-sector collaboration at the point of service delivery due to potential noncompliance or risks of reputational harm. Health and human service leaders described the purpose of cross-sector projects such as AHC in terms of increasing connectedness of, and interprofessional knowledge among, health and human services workers, rather than increasing the ability of their clients to access services. This research suggested the value of multi-sector collaboration through interventions such as AHC may be in increasing organizations\u27 visibility to one another and helping organizational leaders identify partners and better advocate their interests within their community (particularly through community-level data). Achieving balance between this perceived value of collaborations and the perceived cost of new meetings or accountabilities appeared to be a delicate process, easily destabilized when multiple collaborative efforts competed for the role of cross-sector convener in a community. Finally, this research revealed that cross-sector networks of health and social service organizations possessed complex social dynamics, with power exercised by organizations in subtle ways such as control over community meeting agendas and community health improvement plans. Researchers are increasingly identifying the ways that health and social services work is interconnected in its delivery and its outcomes, revealing new opportunities for both sectors to influence one another or try to exercise control over shared resources. As policymakers and organizational leaders seek new ways to promote population health by aligning the design, financing and delivery of health and social services at the community level, this research suggested it may be important to monitor how power is exercised within multi-sector partnerships, recognizing that any effort that aligns organizations around shared health priorities will also direct attention away from some issues, and any effort to establish shared infrastructure for cross-sector coordination will also create new opportunities for these systems to be exploited