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Headnote ABSTRACT New care delivery models that hold providers more accountable for coordinated, high-quality care and the overall health of their patients have appeared in the US health care system, spurred by recent legislation such as the Affordable Care Act. These models support the integration of health care systems, but maximizing health and well-being for all individuals will require a broader conceptualization of health and more explicit connections between diverse partners. Integration of health services and systems constitutes the fourth Action Area in the Robert Wood Johnson Foundation's Culture of Health Action Framework, which is the subject of this article. This Action Area conceives of a strengthened health care system as one in which medical care, public health, and social services interact to produce a more effective, equitable, higher-value whole that maximizes the production of health and well-being for all individuals. Three critical drivers help define and advance this Action Area and identify gaps and needs that must be addressed to move forward. These drivers are access, balance and integration, and consumer experience and quality. This article discusses each driver and summarizes practice gaps that, if addressed, will help move the nation toward a stronger and more integrated health system. Recent legislation, most notably the Affordable Care Act, stimulated the introduction of new health care delivery models and valuebased purchasing that hold providers more accountable for coordinated, highquality care and the overall health of the patients they serve.1 These models hold potential for achieving the Triple Aim of improved patient experience, improved health, and lower costs.2 But maximizing health and well-being for all individuals necessitates a broader conceptualization of health and more explicit connections with a diverse set of partners. The Robert Wood Johnson Foundation (RWJF) formulated the Culture of Health Action Framework to guide efforts in developing this new understanding of health.3 Four core interrelated action areas were identified through which people, sectors, institutions, and jurisdictions could work together to make good health a public value shared equitably across a diverse country. The fourth of these-strengthening integration of health services and systems-conceives of a strengthened health care system in which medical care, public health, and social services interact to produce a more effective, equitable, higher-value whole that maximizes health and well-being for all;4 ensures equal access and opportunity for achieving health; and increases consumer satisfaction through engagement, shared decision making, and transparency. Such strengthening has the potential to better support the nation's most vulnerable, who disproportionately face barriers to access and high-quality care and often intensively rely on a range of public health and social services to meet basic health-related needs. In developing this Action Area, we selected three critical drivers that help define and advance the concept of strengthening the health care system, and we identified gaps and needs that must be addressed to move forward. These drivers, which extend and go deeper than prior frameworks, are access; balance and integration; and consumer experience and quality.5 Access current context Access is defined as the ability of integrated medical care, public health, and social services systems to connect individuals to appropriate and timely information, supports, preventive services, and formal health care. Although access does not guarantee utilization, it is a necessary prerequisite. Barriers such as costs and insurance coverage, location, limited office hours, language, and culture create unequal access to health services, particularly among minority and disadvantaged populations.6 But access becomes a more complex issue when viewed in the context of an integrated health and human service system, in which access also includes the system's ability to link individuals to appropriate preventive and social services that facilitate health and well-being. One example of an effort to help bridge some of these access gaps is the Promotora de Salud Model. Promotoras, or community health workers, share social, cultural, and economic characteristics with the target population and are often drawn from the community itself.7 Promotoras provide culturally appropriate services in the community and function as educators, mentors, advocates, outreach workers, and translators. They thus help people overcome physical access barriers, particularly for those living in rural areas, as well as cultural, linguistic, and social access barriers.8 Many promotoras also provide environmental health and home assessments, promoting changes that will lead to healthier living spaces through education about environmental health hazards.8 Carrying this example forward to other drivers in this action area, promotoras can be considered boundary spanners, working within and across public health, medical care, and social service organizations and processes to facilitate integration across systems and improve the consumer experience. Despite variation in the types of services offered and levels of intensity, this model holds promise for promoting health and well-being, particularly among vulnerable populations.9 generating evidence and implementing strategy A number of frameworks have been used effectively to study access to medical care,410 but the implementation of new care delivery models that draw upon public health, social services, and other community resources highlight the need to revisit these frameworks and models and build upon them. One such example is Ronald Andersen's Behavioral Model of Health Services Use,10 first articulated in the late 1960s, which allows for an examination of equitable and inequitable access and calls out consumer satisfaction as an outcome in addition to health status. Although this model was developed with access to clinical care in mind, it can provide lessons for a broader conceptualization of access under a strengthened health care system. In future research, there is a need to identify effective models that improve access to a range of health-related services, examining in particular whether innovative models developed to improve access for specific populations or regions might be applied more broadly. Balance And Integration current context The culture-of-health definition of access is broadened to demonstrate the range of services that support a comprehensive health care system; that set of services must work in harmony and in better proportion to address desired health outcomes, such as reducing chronic disease burden or the rate of avoidable hospitalizations. Balance refers to how the nation prioritizes and allocates investments (fiscal and otherwise) between prevention and health promotion and acute and chronic care services, and across health care, public health, and social service systems. Integration refers to meaningful connections across public health, mental and behavioral health, social service, and health care systems. Our current structure of siloed systems that are in competition with each other and resource investments that are heavily weighted toward medical care without a broader acknowledgement of the roles of public health and social services in promoting health and supporting health care could pose a barrier to the ability to achieve health equity and improve health and well-being.1114 Balance and integration could be strengthened, for example, through data and information sharing, workforce structures and health care teams that include experts in public health and social services, and shared financial risk. Given that a large (and growing) proportion of the country's gross domestic product (GDP) is being spent on clinical care, it is not unreasonable to ask if health care resources are being spent efficiently. This question of resource allocation is not necessarily calling for a reduction in funding for health care; in fact, costs could go up in the short and intermediate terms as a result of strengthened public health and social service programs, as more individuals (potentially with higher health needs) are identified and connected with relevant services. However, there have been calls for a reduction in the proportion of GDP being spent on clinical care, in part to finance other social investments with direct bearing on health.15,16 At the local level, however, one would anticipate greater differences in resource allocation, as the medical care, public health, and social service needs of the population vary considerably, warranting a different mix of funds to maximize health and well-being in that community. Time is also an important dimension for thinking about balanced investments, as the anticipated gains might be realized quickly or might take years to realize. Adjusting resource allocations alone will not improve health and well-being unless these systems actively work together. Electronic health records (EHRs), for example, have advanced balance and integration across systems. EHRs are praised for their ability to consolidate clinical data, improve quality through clinical decision support tools, and facilitate electronic prescribing.17,18 Relevant data can be easily transferred to providers, and medical histories can be accessed quickly in the event of an emergency. In addition to facilitating integration in the health care setting, EHRs also hold great potential to improve integration across systems by supporting public health surveillance17,18 and connections to social services. In 2014, for example, the Institute of Medicine recommended a set of core social and behavioral domains (such as financial resource strain and social isolation) that should be assessed and included in all EHRs.19 Although such connections require careful attention to issues of privacy and rights, a thoughtful approach to leveraging data to Iinkthe health care, public health, and social services systems to improve outreach and service provision to those in need holds promise. GENERATING EVIDENCE AND IMPLEMENTING strategy Given the importance of balance and integration for health services and systems, a key area of health policy research and practice moving forward lies in identifying how traditionally siloed systems can be transformed into effective, efficient, and integrated systems that can be sustained20 For example, research is needed that directly examines the cost-benefit ratio of social investments (such as housing and food security) for well-being. Other research could inform discussions around resource allocation by modeling health and well-being as a function of health care and social service spending. ReNew search can also examine ways to overcome barriers to integration. For example, it is necessary to understand how to strengthen the sharing and integration of data across health settings. Equally important is the need to understand how to best sustain efforts of integration. These issues collectively raise economic, philosophical, and ethical questions around values, equity, governance, and personal choice21 but are important in this environment of change. Metrics of relative spending across social services, public health, and medical care, as well as indicators of system cohesion (for example, data sharing, ease of navigation within and across systems), will be powerful signals of how health care operates in the future. In recent years, new care delivery models have been developed to specifically address some of these challenges of balance and integration. For example, patient-centered medical homes and accountable care organizations (ACOs) were designed to provide high-quality, coordinated care to their patients, in some cases through largescale system redesign and a whole community approach.20 In early 2016 the Centers for Medicare and Medicaid Services introduced the Accountable Health Communities (AHC) Model, developed to tackle the high prevalence of unmet health-related social needs that contributes to poor health and to address the current gap between clinical care and community services.22 In this model, universal, comprehensive screening in the areas of housing instability and quality, food insecurity, utility needs, interpersonal violence, and transportation needs will be conducted, and affected individuals will be linked to social services.22,23 Questions about whether and how these models most effectively sustain integration; lower health care costs; and improve population health, quality of care, and access to a comprehensive health system will be answered over time and will likely require innovative research de- signs and new methods, given the heterogeneous implementation and anticipated impacts of ACOs and AHCs.24 Answers to these questions will provide important insights for the design of future care delivery models and effective models of balance and integration across health care, public health, and social service systems. Consumer Experience And Quality current context While the United States is undergoing a period of change in care delivery and payment models, there is hope that these models will be able to fulfill what Donald Berwick and coauthors described as the Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.2 When viewed through a traditional clinical lens, the Triple Aim is often interpreted to mean the health, costs, and experiences of a patient population, such as within a provider practice.25'26 But through the lens of a strengthened and more integrated health care system, the Triple Aim has broader interpretability with the potential to improve the health, experiences, and costs of the entire population. Consumer experience across health settings reflects a consumer's overall opinion of his or her health care. It can be influenced by satisfaction with the quality of services received;27 transparency of information; timeliness and convenience of the service;28 and alignment of expectations with individual preferences for language, culture, and beliefs.29 Consumer experience is also driven by the trade-offs consumers are increasingly being forced to make among provider choice, quality of care, and costs- trade-offs that are influenced by social, cultural, and economic access. These experiences and trade-offs are equally relevant for public health and social service systems in support of health and well-being. Collectively, consumer experience can shape health care access and behaviors: If it is positive, individuals might remain engaged, continue to seek services, and build trust over time; if it is negative, individuals might no longer wish to interact with the specific health setting or the broader health care system.27 The changing US demographic makeup requires that the health system deliver care and services in ways that better match the cultural and linguistic diversity of the population.30 Approximately 21 percent of the US population, or more than sixty-four million people, speak a language otherthan English at home, and more than twenty-five million people have limited proficiency in English.3'| Millions also struggle with low health literacy, meaning that they have difficulty finding, understanding, and using information to make informed health-related decisions.32 Ensuring a positive consumer experience requires a concerted effort to create health settings that are equipped to meet the needs of a diverse population.33 Consumer experience is inherently tied to the other two drivers in this Action Area. As systems become more balanced and integrated, services become easier to access and navigate, and transitions within and across care settings become less of a burden.34 The timely transfer of relevant information improves the quality of care and eliminates the need for the consumer to coordinate between various providers and services. generating evidence and implementing strategy While several states have recognized the importance of the consumer experience, it is difficult to make the transition from standards and guidelines to formal health policies that hold organizations accountable for implementation across states.30 Accreditation and policy standards that aim to improve cultural competency, patient-centered care, and communication have been developed by the Joint Commission, the National Committee for Quality Assurance, and the Department of Health and Human Services Office of Minority Health.303536 However, it is unclear whether these standards are effective at promoting change; future research should examine ways to strengthen their impact. Developing cost-benefit analysis on the value of investment in consumer experience might be an important next step to encourage political support for and implementation of such policies and to ensure that consumer experience is being deliberately considered in the development of new financing and care delivery models. More research and tools are needed to support consumer decision making and help consumers identify the trade-offs that optimize health and well-being, which can result in a more positive consumer experience overall. Despite common use of the term \"consumer experience," more research is needed to better define this construct, measure it, and link it explicitly as an important dimension of quality and quality improvement. This is particularly important for public health and social services settings, where measurement around consumer experience is underdeveloped. Conclusion Access, balance and integration, and consumer experience and quality are interrelated drivers that must be prioritized going forward to achieve a strengthened health care system that values social service and public health, as well as clinical care. Drivers in this Action Area should serve as useful indicators that the system is balanced and functioning in a more aligned and integrated manner to promote health and well-being. Targeting system improvements toward vulnerable populations in particular can help address existing inequities in the health care system. Metrics of relative spending across social services, public health, and medical care (as well as indicators of system cohesion) will be powerful signals of how health care operates in the future. *