Community-based organizations (CBOs) have been increasingly pursuing  the goal of building community care hubs (CCHs) that have the capacity to earn revenue through contracts with health care payers. As contracts are signed with payers like Medicare, Medicaid, and commercial plans, it’s critical to expand expertise and infrastructure to collect, protect, analyze, and communicate data analytics between the CCH, its network of service delivery partners, and payers. This includes contracts for services to address social determinants of health (SDOH) and health-related social needs.

Data is currency for establishing and expanding community-clinical contracts

Data analytics is the process of analyzing raw data to draw out meaningful, actionable insights such as identifying trends, outcomes, and areas for improvement on a macro or individual level. Data analytics support CBOs in determining patient outcomes and showing the value of community-based services. These insights help to serve individuals better by showing what works and identifying where gaps or issues exist. This enables the ability to work toward solutions.  Some examples of outcomes include:

• A reduction in emergency room visits through better management of asthma and high blood pressure after participating in a chronic disease self-management program
• A reduction in illness associated with addressing nutrition needs in a specified socio-economic cluster
• A reduction in re-hospitalization among individuals who complete a care transitions program upon hospital discharge
• Identification of high rates of depression among homebound 75+ population

Contracts between CCHs and health care organizations mean community-based providers must align with health care industry standards. Health care organizations must abide by regulatory, accreditation, and contract requirements, as well as industry standards for data management and privacy.  Penalties can accrue if they do not meet benchmarks, contractual requirements, or regulatory compliance. Achieving these successfully may result in incentive payments. So it’s a top priority for payers to contract with CCHs that are capable of maintaining data integrity and adhering to requirements in an accurate and timely manner.

For CBOs, especially smaller ones, data-collection, reporting, and technology can be particularly daunting. This is an area where a CCH can provide important infrastructure and support, which may include:

• Providing a reporting system for partners to use;
• Submitting required reports to the payer for their partners;
• Performing security checks and audits and providing technical assistance and troubleshooting if any issues are found; and
• Onboarding new employees in the use of the reporting system.

Lessons learned from integrated care models—Western New York Integrated Care Collaborative

The Western New York Integrated Care Collaborative (WNYICC) was launched with the strategic intention of seeking payment from health insurers and other payers for the consistent delivery of evidence-based programming. In 2016, WNYICC was incorporated as a stand-alone not-for-profit and it is now considered a CCH serving a 15-county service area. Executive Director Nikki Kmicinski indicated that 50% of WYNICC’s funding currently comes from contract-earned revenue, of which 65% goes to the network service delivery partners.

Key facts about WNYICC:

• The CCH has grown to include 52 voting network members, most of whom are also community service delivery partners.
• WYNICC holds over 20 contracts with different health plans over a broad service area.
• It now offers various lines of business addressing health-related social care needs, each with its own requirements and systems. 
• WNYICC, as the CCH, is responsible for contract oversight and centralization of many of the operations needed to ensure required activities are easier for the delivery partners and health care payers.

The current WYNICC network data infrastructure was created in recognition of the necessary security of information to comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule,  other data security laws and regulations, and the funding available to build the needed infrastructure.

Through WYNICC contracts, there are three core buckets of data processes for the CCH, including:

1. Managing referrals
2. Data sharing between payers, the CCH, and service delivery partners
3. Billing and payment

Each of these processes involves secure information flow at various stages to and from health plans, WNYICC, social care delivery partners/network members, and health care providers.

Overall, the steps in the data process must be:

1. Secure
2. Accurate
3. Easy and user-friendly
4. Efficient—try to automate as much as possible
5. Cost effective

There is an electronic data management system that is part of the infrastructure.  However, there are different data, reporting, referral, and billing systems in use by the different entities.  All these varying systems are not interoperable to date. As the CCH, WNYICC is currently the conduit for secure closed-loop referral and claims data sharing processes. WNYICC is working on various data projects including integrating data into data dashboards, creating quality assurance dashboards, and automating the billing process to reduce or eliminate a number of manual processes.

WNYICC, other hubs, and Health Information Exchanges (HIE) are in different stages of exploring or developing secure centralized social care data systems and/or integrating social care data with HIEs. Prompted by a recently approved New York State Medicaid 1115 waiver, which would create regional social care networks responsible for data integration, WYNICC began convening a Western New York Social Care Data Coalition in 2023.

Building out and evolving data management infrastructure

Organizations may wish to assess their readiness to participate in a CCH or become a CCH network member in order to benefit from centralized infrastructure for complex data management and analytics processes. This can help identify areas for skill building or improvement in order to be ready to actively participate in a CCH.

A few preparatory considerations:

• Assess what service(s) your organization can offer, your value in offering and costs. Knowing your costs is critical for determining the payment rate your organization can accept.
• Develop a value proposition that highlights key services, how they impact health care and financial outcomes, and why partners should work with you.
• What is your organization’s current capacity, and do you have the ability to grow it?
• What are your current workflows and are you willing to adapt them to what CCH delivery partners are required to do under contract?
• What are the technological needs? Does the CCH provide IT support and training?
• Regarding internal leadership, how will you prepare staff and any volunteers as you seek to participate in a CCH?
• Is your organization a HIPAA-covered entity or a non-covered entity? It is important for the types of agreements implemented and training necessary to be in compliance with HIPAA and other federal and state data security and privacy, laws, regulations and policies.
• A tool that may be useful as you consider being part of a CCH is a Network Member Checklist developed by the Aging and Disability Business Institute at USAging.

To explore further, here are a few resources:

• A Turning Point in Electronic Health Information Progress
• ACL Challenge: Innovative Technology Solutions for Social Care Referrals
• Aging and Disability Business Institute at USAging:
  • SHARP Function Checklist: Decision Points for CBOs Considering Working with Social Health Access Referral Platforms
  • Resources for Developing a Community Care Hub
  • Network Member Checklist
  • Lifting the Veil: How Networks Form, Operate, Struggle and Succeed

• Community-Based Organization Information Exchange Under New York’s New Medicaid Waiver,  NY eHealth Collaborative (NYeC) and Manatt Health
• Health Data Sharing to Improve Collaborative Care
• Hospitals Collect and Receive Social Needs Data, but Usage Varies
• How to Build Referral Systems for Community Integrated Health Networks
• SDOH Toolkit and Learning Forum Sessions for the Health IT Community
• Strengthening Connections Between Community-Based Organizations and Health Information Exchanges, August 09, 2022
• Strategic Framework for Action: State Opportunities to Integrate Services and Improve Outcomes for Older Adults and People with Disabilities
• The Gravity Project

Go deeper:

To assist ACL evidence-based falls prevention and chronic disease self-management grantees as well as other community-based service providers, NCOA held four webinar sessions to inform participants about coordinated networks of CBOs led by community care cubs (CCH). Community care hubs and their network partners often start with one or more Evidence Based Programs (EBPs) as their first service offerings.

Each of the webinars focused on different core roles and responsibilities that are important when considering and participating in a CCH. Some themes cross multiple webinars such as contractual commitments for delivery capacity, quality, performance measures, IT security and data integrity. These companion articles provide key highlights and information associated with each webinar. Other relevant information and resources are shared in the articles where appropriate. We encourage you to listen to the webinar and view the PowerPoints to get the full benefit from the webinar series.

Webinar #1: The Important Role of Evidence Based Program Service Delivery Providers in Community Care Hubs – February 28, 2023  

Webinar #2: Quality, Fidelity, and Compliance Expectations for Service Delivery Providers - March 23, 2023  

Webinar #3: The Essentials of Data Sharing in a Coordinated Network of CBOs, April 27,2023  

Webinar #4: Diversity, Equity, and Inclusion: Establishing Standards Across Service Delivery Providers, Leaders and Volunteers, May 23, 2023  

This project was supported, in part by grant number 90CSSG0048 and 90FPSG0051 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.