Community care hubs are a developing model to align health and social care to meet the needs of the whole person, and they might be needed now more than ever.

There has been a growing recognition of the impact of unmet social needs on a person’s health, with the COVID-19 pandemic escalating a broader understanding of the value of services provided by community-based organizations, including area agencies on aging and centers for independent living, to address the social determinants of health (SDOH) and health-related social needs.

Integration with health care has also been a long-standing component of evidence-based program grants at the federal level. The U.S. Administration for Community Living (ACL), with support from the Centers for Disease Control and Prevention (CDC), provided grants to foster the adoption and delivery of evidence-based self-management programs (EBP) and other evidence-based interventions (EBI) as well as promote the development of contracting opportunities with health insurers and health systems. Recognizing the value of EBPs/EBIs for maintaining and/or improving health and wellness, these grants encouraged CBOs to collaborate to form CCHs to efficiently establish a “one-stop” contracting entity for payors and CBO service providers. Simultaneously, the Centers for Medicare and Medicaid Services (CMS) and CDC are promoting efforts to bring together health-related social needs (HRSN) and health care through models such as the Accountable Health Communities and Umbrella Hubs, respectively.

Further, new opportunities for CCHs or similar CBO-led networks are developing in states undertaking Medicaid system delivery payment reform in the form of value-based payment models. Several Medicaid 1115 waivers that include investments in addressing HRSNs, as well as policy changes such as billing codes in the CY 2024 Medicare Physician Fee Schedule for services addressing health-related social needs, are also moving efforts forward to align social and health care.  

A CCH is a developing and evolving model. How a CCH operates in one state or region may look a bit different from another. One thing that is evident: CBO participation is growing!

The percentage of CBOs contracting as part of a network doubled between 2017 and 2021, from 20% to 40%.

Of note is the growth and changing nature of language and acronyms to further describe a more holistic view or approach in efforts to align social and health care. For example, social drivers of health may interchange with SDOH. States and regions may prefer to use different naming conventions and terminology for branding purposes or nuance in the CCH-type models being developed. The evolving model has foundational elements and, by design, considers the needs and environment within which it is developing or expanding. 

What is a community care hub,  and why should CBOs participate?

What is a CCH?

A CCH is a community-focused entity that organizes and supports a network of community-based organizations providing services to address health-related social needs. A CCH centralizes administrative functions and operational infrastructure, including but not limited to, contracting with health care organizations, payment operations, management of referrals, service delivery fidelity and compliance, technology, information security, data collection, and reporting.¹

A CCH has trusted relationships with and understands the capacities of local community-based and health care organizations and fosters cross-sector collaborations that practice community governance with authentic local voices.

The above comprehensive definition of a CCH was vetted by the Partnership to Align Social Care through a workgroup of varied, cross-sector stakeholders. Embedded in the definition are some primary benefits for CBO service delivery providers to participate.

National learning community

From November 2022 through August 2023, ACL, in partnership with CDC, hosted a Community Care Hub National Learning Community (NLC) with two learning tracks: Network Development which focused on the foundational elements of developing a CCH; and Network Expansion that covered topic areas that align with supporting expansion of an existing CCH (e.g. housing stability, billing, coding and payment, etc.). NLC participants were provided access to vital peer support, technical assistance from national experts, and information on resources, initiatives, and collaborations aimed at furthering the capacity of CCHs nationwide. Across the two cohorts, there were 58 participating organizations from 32 states.² 

ACL will host another NLC from November 2023 through August 2024, building on the curriculum and other technical assistance of the 2022-2023 cohorts, including use of the ECHO Model® “all teach, all learn” approach and individual consulting with subject matter experts.

How can the CCH help CBOs perform their work? What is the role and some expectations of the participating CBOs?

The CCH’s strength is in the capacity of its provider network to delivery contracted services.
--Sharon Williams, Williams Jaxon Consulting, LLC (Webinar #1)

The chart below further illustrates some of the functions and features of the community care hub and the community-based organization role as a network service delivery partner.

“Our Hub is successful when our partners are successful," said Katie Zahm, Program Manager for Illinois Pathways to Health by AgeOptions. “The CCH  goal is to centralize services and streamline processes so partners can focus on service delivery.”

A community care hub example

AgeOptions Illinois Pathways to Health, a CCH, currently provides a variety of evidence-based self-management and falls prevention programs. Technical assistance and training, program material templates, process sheets and guides, marketing templates, and increased brand awareness are a few of the activities and products this CCH provides to service delivery partners.  Partners range from very small CBOs delivering programming a couple of times a year to large organizations with capacity to offer EBPs monthly. The service delivery partners’ responsibilities include delivering workshops with program fidelity, registering all workshops on Illinois Pathways to Health’s website, submitting required documentation and data, and agreeing to facilitate programs under plan contracts.

Marketing community care hubs to payers and CBOs

There are a variety of ways, including direct contact, a CCH reaches out to potential payers and service deliverers. A couple of examples used by established CCHs to raise awareness and interest in partnering:

• Illinois Pathways to Health created EBPs marketing materials for healthcare providers and insurers. It also includes downloadable materials.
• Western New York Integrated Care Collaborative (WNYICC) CCH developed a one-pager on what are the benefits of joining their network.

More about coordinated networks of CBOs/community care hubs

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, now commonly known as community care hubs (CCH). CCHs 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 – Feb. 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

Related resources

• HHS’s Strategic Approach to Addressing Social Determinants of Health
• to Advance Health Equity – At a Glance - April 1, 2022
• Functions of a Mature Community Care Hub
• Resource Guide: Partnerships with CBOs: Opportunities for Health Plans to Create Value
• The Roadmap to Community-Integrated Health Care
• Community Care Hubs: Making Social Care Happen
• Community Care Hubs National Learning Community
• Community Care Hubs: Making Social Care Happen Background, Evolution, and Value Proposition of Working with a Local CBO Network Led by a Community Care Hub
• Advancing Partnerships to Align Health Care and Human Services
• Improving Health And Well-Being Through Community Care Hubs | Health Affairs
• Advancing Partnerships: Contracting Between Community-Based Organizations and Health Care Entities
• Network Member Checklist: Considerations for CBOs Deciding to Join a Network - Aging and Disability Business Institute

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.

Sources

1. Partnership to Align Social Care. Community Care Hubs: Making Social Care Happen. Found on the internet at https://www.ta-community.com/media/download/80jb36/CCH-Primer-Final.pdf

2. U.S. Administration for Community Living. Advancing Partnerships to Align Health Care and Human Services. Found on the internet at https://acl.gov/programs/strengthening-aging-and-disability-networks/improving-business-practices