Dietitians as Boundary Spanners: A Case Study of a Cross-Sector Health-Related Social Needs Program

Integrating medical and social care requires professionals to navigate and connect distinct systems. In collaboration with a Massachusetts Medicaid Accountable Care Organization (ACO), registered dietitians from partner community-based organizations (CBOs) implemented a medically tailored nutrition program to address food insecurity among clinically complex patients. This study asks: How do dietitians act as boundary-spanning professionals within a cross-sector nutrition program, and how does this work enable integration of medical and social care?

We conducted a qualitative case study using semi-structured interviews with nine dietitians from CBOs collaborating with a Massachusetts Medicaid ACO. Guided by Complex Adaptive Systems theory, the boundary spanning literature, and empowerment theory, we applied the Framework Method to examine how dietitians navigate cross-sector work, adapt to system challenges, and strengthen their skills through collaboration.

Dietitians described the system as dynamic and interdependent, requiring ongoing adaptation. They described aspects of the ACO partnership as collaborative and supportive, enabling them to learn, adjust, and serve patients more effectively. Dietitians saw boundary spanning as exciting and mission-driven work. Cross-sector collaboration strengthened and broadened dietitians' skill set as they learned to use advanced communication and relationship-building skills to overcome challenges such as limited access to patient data and varying information systems. Working within a CBO allowed them to address patients' social needs, while connection to the health sector gave them access to patients who could benefit from nutrition supports. Dietitians met challenges with innovative patient-centered problem-solving, creativity, and flexibility, demonstrating adaptive capacity within a complex care ecosystem.

Dietitians demonstrated strong boundary-spanning capacity, using cross-sector work as an opportunity to connect systems, refine their practice, and deliver more responsive nutrition care. Their success in meeting patients' needs was in part due to a flexible collaborative model that empowered actors to serve patients holistically.