Social Care Needs Real Networks: Halima Ahmadi-Montecalvo, PhD, MPH

North Carolina and Ballad Health's social care initiatives succeeded because they built coordinated delivery systems rather than isolated referral pathways, according to Halima Ahmadi-Montecalvo, PhD, MPH, adjunct professor of public health at the Milken Institute School of Public Health at George Washington University and vice president of research and evaluation at Unite Us.

Structured Partnerships Set These Programs Apart

Both initiatives established formal relationships among health care organizations, payers, and community-based providers, Ahmadi-Montecalvo said. They built clear workflows for identifying patient needs and connecting people to services, along with the infrastructure to track activity across organizations. That scale allowed each program to generate meaningful operational and outcomes data—something narrower pilots often cannot produce.

A defining feature of both efforts, she said, was that community organizations were treated as part of the care delivery infrastructure rather than as an informal add-on. That meant defined roles, payment mechanisms, shared technology, and accountability for what happens after a referral is made.

Technology Alone Cannot Produce Outcomes

Ahmadi-Montecalvo said the lesson from these initiatives, along with other evaluations she and her partners have conducted, is that meaningful outcomes never come from technology alone. Technology is one piece of a larger system that must also include network development, financing, community capacity, and clear expectations for service delivery and measurement.

She pointed to program design and evaluation as areas she returns to often, stressing the importance of establishing outcomes and a specific program design before an initiative can succeed. North Carolina and Ballad Health took a hands-on approach to ensuring each of those pieces was in place and functioning as part of a genuine collaborative partnership, she said.

"If you ignore those key pieces," Ahmadi-Montecalvo said, "[it is] very likely that the initiative is not going to produce the results that you're looking for."