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Toolkit ·

Aligning State Systems for Improved Health and Well-Being Outcomes: A Framework for Collaborative Change

A practical framework for state leaders looking to better align state systems and improve health outcomes.


State leaders across health, human services, and other agencies — including Medicaid, early childhood, public health, child welfare, among others — are uniquely positioned to develop programs and services that support the health and well-being of people in their state. Despite the shared goal of helping individuals and communities to thrive, however, agencies often operate in siloes or in misaligned ways that create challenges for the people they serve.

This framework can serve as a practical guide for state leaders looking to better align state systems and improve health and well-being outcomes. The framework grew out of Aligning Early Childhood and Medicaid, a national initiative led by the Center for Health Care Strategies (CHCS) with support from the Robert Wood Johnson Foundation, which convened cross-agency state teams to enhance alignment across Medicaid and other agencies responsible for early childhood services. The framework has been tested and refined with public sector leaders working with CHCS and NAMD.

This framework includes nine key activities to support health, human services, and other agencies in collaboratively engaging with the individuals and families they serve; working with state colleagues and other partners to address misalignment and gaps; and co-creating more effective programs and services.

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When programs are aligned across sectors, they can better serve community members. In Season 4 of the Medicaid Leadership Exchange podcast, guests from all corners of the public sector — behavioral health, criminal justice, and housing, among others — sat down to discuss how resources can be more impactful and efficient when everyone rows in the same direction. This framework can help expand upon the lessons described in the podcast.


1. Establish the Key Elements of Effective Collaboration

The first step to aligning state systems is establishing collaboration across stakeholders, which can include cross-agency partners, community-based organizations, community members, and providers. Effective collaboration requires shared vision and commitment; influential and adaptive leadership; nurtured, trusting, and equitable relationships; and structures to support collaboration, including effective meeting strategies as well as decision-making and accountability mechanisms. As states focus on alignment efforts, ensuring that these elements are in place at each stage of the process is vital for long-term success.


2. Identify the Challenge or Opportunity for Alignment

All systems alignment efforts should be centered on supporting adults, children, and families to achieve the maximum benefit from the program and services they receive. States typically identify challenges in their systems through structured needs assessments, formal evaluations, program monitoring and reporting, or through issues raised by families, communities, or state policymakers.

3. Engage Partners, Community Members, and Stakeholders

As challenges or opportunities for alignment are identified, it is important to strategically convene and engage cross-agency state partners, community members, and other stakeholders, including providers, advocacy partners, and state policymakers around a central alignment focus. State agencies can use a variety of approaches to engage and learn from stakeholders, including townhall forums, listening sessions, surveys, standing meetings, working committees, and formal advisory councils. They can also partner with community organizations with cultural and linguistic competency and established community trust to effectively engage families and communities.

4. Map the Current Systems

To change a system, state leaders and partners must understand current investments and logistics of current programs, including operations, reach, and interactions across services. States can understand their current systems by mapping the journey of an individual through the system, cataloging current programs and services that serve similar populations or address similar issues, and using fiscal mapping to capture all current investments in the system.


5. Identify Desired Change and Co-Create Solutions

Systems and programs can be improved to increase their capacity to meet the needs of individuals and families by expanding access to, improving the experience of, or creating new services. Systems can also be aligned to improve connections between programs and services that support individuals and families along the continuum of care. Co-creating solutions with those most impacted by the systems — including individuals, families, and providers — is a crucial step to creating impactful change.

6. Determine the Most Impactful Levers

Available levers for states to improve and better align systems and programs include:

  • Laws, regulations, and policy — changing program rules and regulations;
  • Financing adding incentives, removing constraints, and increasing accountability;
  • Program structures — aligning program administration, provider requirements, etc.;
  • Procedures ensuring alignment of operational processes within or across system components;
  • Culture, norms, and knowledge — establishing expectations and ensuring alignment among individuals, providers, staff, administrators, and other stakeholders; and
  • Data agreeing on shared data and measurement approaches across the system.


7. Implement and Support the Change

Some changes within systems can be implemented quickly and easily, while others may require new authorities, regulations, or financing. All efforts require focused change management strategies — including transparency, clear timelines, effective communications, training, etc. — that help engage individuals and families served by systems and programs, as well as service providers, agency staff, and other stakeholders.

8. Monitor the Impact

To effectively measure the impact of systems change, state leaders need a strategic evaluation and monitoring approach. States can measure impact by focusing on individual and family experiences and outcomes, provider experiences and outcomes, and overall systems efficiency and operations.

9. Create Feedback Loop to Share Outcomes and Improve

Ongoing community partnerships as well as feedback loops with community members and providers engaged in the work are critical. These feedback loops create opportunities to intentionally share the outcomes and impacts of systems alignment efforts so that success can be celebrated and ongoing challenges or new influences on the systems’ performance can be collaboratively addressed.


Build Health Challenge. “Community Approaches to System Change.” November 2019. Available at:
Latham. “A Practical Guide to Evaluating Systems Change in a Human Services Systems Context.” Learning for Action, 2014. Available at:
Robert Wood Johnson Foundation. “Aligning for Better Health.” 2023. Available at:
Center for Health Care Strategies. “An Introduction to the Framework for Public Sector Leadership.” September 2020. Available at:

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