Design and content validation of AUTIVA: an ecobiopsychosocial instrument for childhood autism.

Many US health care organizations have implemented health-related social needs (HRSN) programs to help prevent and treat chronic disease, reduce healthcare costs, and address health inequity. To accomplish these goals, some health systems establish formal partnerships with community-based social service organizations (SSOs) and financial contracts to pay SSOs for services rendered to their patients. SSOs serve as essential partners to health systems as they are known and trusted entities that have the operational capacity and expertise to deliver targeted social needs interventions in their communities. However, developing sustainable cross-sector partnerships between SSOs and health systems is complex and resource-intensive, with inherent challenges in data sharing, closed-loop communication, and implementation of intervention protocols. Identifying factors that facilitate these partnerships can guide health care organizations in the implementation, adoption, and maintenance of HRSN programs over time. Health system-based HRSN interventions have the potential to improve food and housing security, but the design and duration of these programs vary greatly, their impact on health outcomes is variable, and implementation is understudied. Increasingly, policy approaches to addressing HRSN are being implemented as part of payer and health system strategies to address poor health outcomes and disparities driven by socioeconomic inequality. As of January 2026, Medicaid agencies in 25 states have received approval for Section 1115 demonstration waivers to use Medicaid funding to address HRSNs such as food insecurity and housing instability. In March 2025, the Centers for Medicare & Medicaid Services rescinded prior guidance encouraging the submission of new Section 1115 demonstration waivers addressing HRSN; however, existing waivers have remained in place. Many of these programs include formal partnerships between health systems and SSOs, often with financial contracts to pay SSOs for services delivered. In 2017, Massachusetts Medicaid (MassHealth) initiated accountable care organizations (ACOs), and in 2020, MassHealth launched a pilot of the Flexible Services Program (FSP), a $149 million initiative that provided funding to ACOs statewide to contract with SSOs to address food and housing insecurity among eligible Medicaid patients. FSP was authorized through a Section 1115 demonstration waiver and funded through a Medicaid performance-based Delivery System Reform Incentive Payment. A previous study explored the first 17 months of FSP implementation from the perspectives of one ACO's patients and health system staff. The current study examined FSP implementation over the full 3-year pilot (March 2020 to March 2023), focusing on the benefits and complexities of cross-sector contracts and incorporating firsthand perspectives from staff within participating SSOs and the ACO. Using mixed methods, findings from quantitative FSP enrollment data were integrated with qualitative interviews with ACO and SSO stakeholders, focusing on their experiences with implementing FSP. The objectives were to identify key challenges and solutions for successfully implementing partnerships between the ACO and SSOs.