Health care providers and systems are increasingly interested in approaches that address both medical needs and social determinants of health (SDoH). SDoH are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks and outcomes.  They have a substantial impact on the health of many Americans and are a key driver to address health inequities.” Health equity is “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance’”.  Studies examining the impact of SDoH found that 60 percent of the factors that influence health are non-medical social, behavioral, and environmental factors, while 20 percent are genetic, and the remaining 20 percent are health care factors.  Nearly as many deaths are caused by social factors as by behavioral or pathophysiological factors. 
Early efforts to address health determinants have occurred within siloed delivery systems, with health care providers addressing individuals’ medical needs and community-based service organizations (CBOs)  addressing social, functional, and environmental needs. While these efforts have made significant progress, individuals that interface with both the health care and community service system often experience inefficient, uncoordinated care that can result in higher health care costs, lower satisfaction with care, and poor outcomes.  As both systems embrace person-centered approaches to address health determinants, aligning the systems and leveraging the strength of health care and social service providers has been a successful approach to coordinated, holistic, person-centered care. This is further encouraged in the National Strategy for COVID Response and Pandemic Preparedness which highlights the need to facilitate linkages between clinical and social services given the increased need for social services during the COVID-19 pandemic, as well as the need to work with community-based, multi-sector organizations to align health and social interventions.
The need to reduce health care utilization while improving quality of life, as well as promoting the self-management of chronic health conditions, is more important than ever as the health care sector transitions to value-based payment models. Integration of care allows for the provision of services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-clinical risk factors. These essential services are shown to improve health outcomes and reduce the cost of care. This is particularly true for “high-need, high-cost” people who have complex health conditions and social risk factors and who often have significant functional limitations. Moreover, care planning for such individuals needs to go beyond a medical orientation and take into account an individual’s values, preferences, and holistic needs including social, functional, financial, and medical needs.
Launched in 2012, ACL’s business acumen efforts have aimed to strengthen CBO networks from the inside, building their business skills, enhancing their effectiveness, efficiency, and sustainability. Over the course of nearly a decade, these efforts have brought together practical resources, subject matter experts, and technical assistance to promote the successful alignment of health care and social services. The fundamental idea is this: when services from CBOs and health care entities are well aligned, consumers win.
States also have a vested interest to address and reduce health disparities – meeting the unique health and social needs of citizens with variation in culture, economic, and environmental considerations. For several decades, the Administration for Community Living (ACL) and its federal partners have invested in state-level infrastructure and systems change to enhance, streamline access, and align social services in communities for all populations and payers. These investments have been supported by a variety of initiatives, including the Aging and Disability Resource Center (ADRC) program, Real Choice Systems Change grants, the Balancing Incentive Program, Money Follows the Person (MFP), and Veteran Directed Care (VDC). ACL has helped states to streamline processes and implement person-friendly systems that make it easier for persons and their families to learn about and access the services they need.
To align these federal initiatives, ACL, with its federal partners, developed the No Wrong Door (NWD) System vision, which includes national standards, tools, metrics, and best practices that all states can use to develop a single “high performing” access system. In these systems, multiple agencies at the state and local level coordinate to create a simplified process through which individuals of all ages, abilities, and incomes can get unbiased information and one-on-one counseling with community health workers  on the options available in their communities.
The foundation of NWD Systems are supported by four key functions:
State Governance and Administration;
Public Outreach and Coordination with Key Referral Sources;
Person-Centered Counseling; and
Streamlined Eligibility to Public Programs.
The NWD System is designed to serve all populations who may need any long-term services and supports (LTSS), regardless of payer. This includes people who represent a variety of ages, incomes, nationalities, citizenship statuses, cultures, gender identities and expressions, sexual orientations, languages, or disabilities. At its core, a state NWD System is a network of CBOs comprised of community health workers, such as information and assistance specialists, person-centered counselors, etc., that manage access functions and processes to maintain independent living in the community. CBOs have unmatched expertise in understanding local culture and needs, service coordination and delivery, and securing benefits, services, and supports that maximize independence. In addition, the breadth of community health workers residing in a state’s NWD system are best positioned to understand a person’s preferences for community living; these preferences may differ depending on an individual’s age, race, culture, social and family support, as well as which applicable services and supports are important to a person and for a person.
The current literature (see References section of hyperlinked text) shows community-based organizations are more likely to successfully expand their missions to support the diverse needs of individuals and families in the community if they belong to integrated networks with diverse partners. Additionally, the literature suggests that efforts to improve medical outcomes and lower costs by addressing SDoH will be more effective if CBOs, health plans, and health systems develop formalized partnerships within collaborative networks. Through this funding opportunity, applicants will be expected to organize new or enhance existing community integrated health networks (CIHNs) led by a network lead entity (NLE). For the purpose of this funding opportunity, CIHNs are defined as coordinated groups of visible and trusted CBOs lead by a NLE that have entered a formal partnership with health care organizations. These network structures provide a common pathway for private health care entities to contract with multiple community-based service organizations that are supported by the policy, technology development, and resource allocation within a state’s NWD System.
Network Lead Entities offer one-stop contracting for multiple proven interventions and services that maintain independence and can be conducted in an individual’s home, in a person-centered fashion. The NLE serves as the hub for coordinating the services of the wider network, providing a unified and consistent approach to program delivery across a geographic area. It also provides the business operation and administrative oversight of the network and takes the lead in network governance responsibilities.
Establishing CIHNs led by NLEs gives these networks the capacity to:
Deliver a broad scope of SDOH services;
Reach more diverse consumers and traditionally hard-to-reach populations;
Build stronger administrative infrastructures;
Capitalize on economies of scale;
Provide expanded geographic coverage at various levels – regional (within a state), statewide (throughout an entire state), and multistate (across state lines in a specific region or statewide in multiple states);
Offer one-stop contracting for multiple services with different payers; and
Expand quality improvement initiatives and successes.
States have an opportunity to strengthen and support the evolution of the aging and disability network to deliver high quality, coordinated services in an increasingly value-based, integrated care environment. In addition, with the support and leadership of state NWD Systems, CBOs can continue playing a vital role in facilitating alignment across health care and social services. There is a time-sensitive window of opportunity to directly address health equity in this country by addressing both 1) equitable access to SDoH-related services through a culturally competent and coordinated statewide access system by leveraging a state’s existing NWD System; and 2) equitable distribution of SDoH by aligning healthcare and social services through the enhancement and expansion of NLEs/CIHNs to increase SDoH availability and delivery.
 Social Determinants of Health. Centers for Disease Control and Prevention, 9 Mar. 2021, www.cdc.gov/socialdeterminants/index.htm.
 Whitehead, Margaret and Göran Dahlgren. WHO Collaborating Centre for Policy Research on Social Determinants of Health University of Liverpool, 2006, Levelling up (Part 1): a Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health.
 Blue Cross Blue Shield of Massachusetts Foundation, 2015, Leveraging the Social Determinants of Health: What Works?
 American Academy of Family Physicians, 2019, Advancing Health Equity by Addressing the Social Determinants of Health in Family Medicine (Position Paper).
 Community Based Organizations (CBO) may include Area Agencies on Aging, Aging and Disability Resources Centers, Centers for Independent Living or other aging and disability network agencies.
 Hopson, Chris. “Health and Social Care Integration: How Do We Make It Work?” The Guardian, 18 Sept. 2013.
 According to the Centers for Disease Control and Prevention, a community health worker (CHW) is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served. A CHW serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery.
This funding opportunity aims to support NLEs that are part of ACL’s aging and disability network and are performing access functions as part of a broader NWD System. Please see Appendix A for a list of these access functions. Through a Cooperative Agreement, ACL will support up to 10 NLEs with innovation grants to improve their access functions and support infrastructure costs associated with aligning health care and social services to address SDoH for all populations. A NLE is an organization that helps to create a CIHN at the regional, statewide, or multistate level. The NLE directs the development and design of a network structure and facilitates services, administrative oversight, and governance responsibilities.
Profile of the Leading NLE
In response to the rise in health care financing opportunities, the demand for home- and community-based services to be delivered across larger geographies, and a new frontier of competition, the leading NLEs are evolving to become viable, competitive enterprises that meet and create demand for their services and gain market share in their regions. These leading NLEs are shaped by external market forces and through continuous internal improvements to their processes, infrastructures, and standards of practice. The field of NLEs is established enough today to allow for the core business processes of a network lead entity to be identified, to recognize best practices, and to generate a profile of the leading NLE that demonstrates proficiency across each business process. NLEs and their networks are organized and governed in numerous ways.
While each NLE is unique in how it builds and sustains its network, there are foundational business processes that leading NLEs are performing. Leading NLEs are characterized by their ability to sustain multi-year contracting with multiple health sector partners, follow strategic planning and standard business processes, and employ at least one full-time staff member committed to network management. The aggregation of these NLE business processes have been informed by best practices observed in the field as well as best practices from business and management to generate a profile of the leading NLE. The processes of the leading NLE can be organized into five categories or domains.
Leadership: Strategic Planning, Organizing the Network, Controlling Network Performance, Leading Across Organizational Boundaries;
Finance: Capitalization, Cost Management, Pricing, Making the Business Case;
Business Development: Assessing the Market, Positioning the Network’s Services, Communicating Value Externally, Building a Health Sector Partner Base;
Network Development and Support: Communicating Value Internally; Vetting, Onboarding, and Assistance; Monitoring and Managing Performance, Retaining Network Service Providers; and
Network Administration: Strengthening Information Systems, Managing Contracts, Meeting Compliance Standards, Billing and Payments.
ACL’s aging and disability network is composed of community-based organizations that offer community living services and supports to advance the health, well-being, independence, and community participation of people with disabilities and older adults. These organizations include Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), Centers for Independent Living (CILs), developmental disabilities organizations, University Centers for Excellence in Developmental Disabilities Education, Research and Service (UCEDDs), Protection and Advocacy Agencies, behavioral health organizations, aging services organizations, faith-based organizations, Native American tribal organizations (American Indian/Alaskan Native/Native Hawaiian), nutrition program providers, and other local service providers for persons with disabilities and/or older adults. Additionally, for the purpose of this funding opportunity, as noted in the Purpose section above, CIHNs are comprised of coordinated CBOs lead by a NLE that have formal partnerships with health care organizations. CIHNs reflect collaboration between health care organization and social service networks and are associated with higher performance and reduced health care costs. CIHNs are led by a NLE, an organization that assumes responsibility for directing the development and design of a network structure, facilitates services, and provides administrative oversight and governance. A significant advantage of NLE-led CIHNs is their capacity to provide services at different geographic levels to meet the market demand of health plans’ and systems’ geographic footprint, such as (1) Regional; (2) Statewide; and (3) Multi-state lines. The core set of guiding principles of CIHNs include:
Trust: Networks leverage established relationships in the community and in the home to ensure that individuals feel understood and supported.
Leadership: Social service and health care decision makers share leadership responsibilities in planning and managing social assessments, referrals, service delivery, and team-based, holistic care.
Accountability: Social service leaders implement a system of accountability and quality improvement at all levels using agreed-upon performance benchmarks, frameworks for data sharing and regular reporting, and data-driven strategies for improvement.
Sustainability: Networks finance services that address SDOH through multi-payer arrangements that build community capacity. Over time, they transition from a fee-for-service payment model to value-based/risk-based payment models for delivering social services in comprehensive, coordinated care environments.
Innovation: To maximize efficient delivery of services and health outcomes, networks implement, evaluate, and iterate evidence-based interventions and innovative care models.
Use of Funds
A particularly common and significant challenge experienced by NLEs involves the readiness and willingness of some service providers in the network’s geographic coverage area to join the network and meet the performance standards necessary to fulfil contractual obligations. Many of the service providers require unanticipated levels of personnel time and financial resources of the NLEs to demonstrate the value of joining the network, to help service providers meet the standards for contracting, and to offer guidance on how to manage contracts and services that produce value. Leading NLEs are finding that they need to expand network service provider eligibility criteria to include private for-profit organizations in order to meet the performance and compliance obligations in their health sector contracts. Some are also hiring their own direct service staff to fill gaps in network coverage. These and other challenges experienced by NLEs cause delays in planning and implementation, create gaps in service area coverage and limitations on potential service volume capacities, hinder the NLE’s own growth and advancement, and can ultimately prevent or jeopardize health sector partnerships.
Common Challenges to NLE Success
When considering the growth and advancement of NLEs, there are some common challenges to tackle and provide areas that NLEs may wish to utilize grant funding. Challenges include:
Difficulties in implementing business development plans
Poorly conceived contracting tactics
Expensive and complex information technology
Non-compliance of network service providers
Underdeveloped cost accounting systems
Lack of service provider readiness
Narrow service provider boundaries
Need to expand populations
Develop and Enhance Administration Structure and Functions
The development and enhancement of NLEs provides a unified and consistent approach to program delivery across a geographic area, including management of critical business operations, administrative oversight, and establishment of governance responsibilities. To build and strengthen the operations, infrastructure, and sustainability of NLEs and CIHNs for delivery of home and community-based services and supports in contract with health care entities, funds can be used to:
Assess business requirements to operate as a Network Lead Entity (NLE), including insurance liability requirements and gaps in liability coverage that may prevent participation
Staffing / Leadership / Governance
Assess competencies of key staff performing access functions of NLE
Provide relevant trainings in cultural competency, person-centered counseling, social service coordination, etc.
Develop mechanisms for managing staff training across CIHN partner organizations to ensure service excellence and a culture of quality improvement.
Assess CIHN partner organizations representing underserved populations as defined by Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.
Develop mechanisms to curate and evolve CIHN partner organizations to meet the needs of populations over time related to nutrition, housing, transportation, behavioral health, and/or other social determinants of health.
Develop mechanisms for managing sub-contractual relationships, develop and implement NLE infrastructure to pay CIHN partner organizations (i.e., subcontractors).
Assess network financial and legal liability for managing risk relevant to participation in contracting.
Conduct cost benefit assessments to determine the financial costs and risk to the network in contracting.
Determine a process for blending and braiding funds from available public resources and health care contracts (enabled by the NLE and supported across the CIHN).
State-level benefits and Medicaid reimbursement (e.g., reimbursement for SDOH assessment, social care coordination, state funded nutrition and transportation assistance, etc.) can be factored into a blending and braiding process.
Information Technology (IT) Infrastructure
Assess the health IT requirements for contract performance, including hardware, software, business processes, and privacy and security requirements.
Assess ability of CIHN partner organizations to file all claims electronically.
Assess requirements and opportunities for shared IT services that are needed to function as an NLE but obtained through a collaboration across NLEs.
Quality Assurance and Service Delivery Compliance
Determine flow of contracting requirements, metrics, and performance evaluation of CIHN partner organizations.
Conduct readiness assessments and regular report cards.
Conduct process mapping for service activation and relevant follow up to ascertain service delivery outcome.