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Advancing Partnerships to Align Health Care and Human Services

Health care in the United States continues to undergo rapid change, presenting both opportunities and challenges for community-based aging and disability organizations (CBOs). These organizations meet many health care related needs of people with disabilities and older adults, such as addressing nutrition issues, providing transportation to medical appointments, assisting with vaccine access, and providing personal assistance with daily activities, allowing people to live in their own homes. Demand for CBO assistance with these “social determinants of health” continues to grow, but funding and other resources for these community organizations are often scarce.

Since 2012, ACL, with public and private partners, has worked to strengthen aging and disability CBOs from the inside by helping them build their business skills and enhance their effectiveness, efficiency, and sustainability. This successful effort has often resulted in the formation CBO networks that are more sophisticated and capable of operating in today’s complex business environment. At the same time, each CBO has maintained its status as a trusted broker within the community it serves.

Over the years, ACL’s emphasis has evolved from improving the business practices of individual CBOs, to supporting the development – and enhancing the capacity – of CBO networks. A major part of this evolution has involved connecting CBO networks to health care systems. Today’s local, statewide, and regional CBO networks are often led by Community Care Hubs, which allows them to become more efficient and intricately connected to health plans and providers in their local area or a larger geographic region.  This evolution in business practices is premised on the concept that when CBOs and health care entities are well integrated, the people they collectively serve will experience better overall health, maximizing their independence and ability to live in their community of choice.

Aligning Social Services and Health Care through Community Care Hubs

Adopting the Community Care Hub (CCH) approach can help CBOs and health care payers and providers increase a community’s capacity to address health-related social needs. The hub centralizes administrative functions and operational infrastructure. This infrastructure includes contracting with health care organizations, payment operations, management of referrals, service delivery fidelity and compliance, technology, information security, data collection, and reporting. The hub has trusted relationships with, and understands the capacities of, local community-based and healthcare organizations and also fosters cross-sector collaborations that practice community governance with local voices by engaging with CBOs and the individuals they serve.

Building the capacity of Community Care Hubs is an essential component of ACL’s vision of coordinated person-centered care supports for people with disabilities and older adults who have health-related social needs.

ACL Investments Supporting Community Care Hubs

Community Care Hub National Learning Community

ACL, with support from the Centers for Disease Control and Prevention (CDC), launched the Community Care Hub National Learning Community in November 2022. This learning community brings together organizations serving as Community Care Hubs that are either in development or interested in expansion. Participants take part in shared learning, information and resource sharing, and coordinated technical assistance with the goal of strengthening each hub’s ability to address health-related social needs and public health needs through contracts with health care entities.

The National Learning Community includes two tracks: one for organizations interested in developing their capacity to serve as a Community Care Hub (Network Development track) and another for established Community Care Hubs seeking to enhance and expand their administrative and service delivery capacity (Network Expansion track).

2021 No Wrong Door Community Infrastructure Grants: Scaling Network Lead Entities 

Twelve cooperative agreements totaling $3.48 million were awarded to support Network Lead Entities* (i.e., Community Care Hubs) that are part of ACL’s aging and disability network and are performing access functions as part of a broader No Wrong Door System. These awards provide funding directly to community-based organizations serving as a hub to develop or enhance CBO networks that contract with health care sector entities (e.g., accountable care organizations, health plans, managed care organizations, hospitals, health systems, and more) for coordinated access and delivery of services that address health-related social needs.

*A Network Lead Entity is the former term for what is currently referred to as a Community Care Hub.

Strengthening CBO Network Capacity

The resources below were developed to highlight the value of CBO networks and the services they offer, as well as encourage the expansion of these networks.

Community Care Hub IT Playbook 

This Community Care Hub IT Playbook is a self-guided tool on the technical and information technology (IT) infrastructure necessary to support collaboration between CCHs, the network of CBO providers, and health care partners.

The Playbook focuses on the crucial aspects of IT infrastructure and technology that support CCHs in their network management, contractual arrangements, and service delivery, including data management, security, hardware and software requirements, interoperability, and shared services. It is tailored to help readers understand the advantages and processes of integrating business functions with IT solutions.

For ease of navigation, the Playbook is divided into two parts with corresponding appendices. Part I of the Playbook provides a holistic understanding of how to leverage IT and shared services to enhance CCH operational efficiency and service delivery. Part II delves into more technical details and addresses regulatory data requirements and contract preparation.

Download the Executive Summary and full Playbook below.

Sustainability Spotlight

The resource below features a detailed overview of the process undertaken by the Western New York Integrated Care Collaborative to offer a health coaching intervention in partnership with a local Medicare Advantage plan.

Community Care Hub Contracting Spotlights

The three spotlighted examples below highlight CBO networks that have successfully contracted with health plans to offer various services that address health-related social needs. Each spotlight features information on the CBO network structure, interventions offered, health plan partner(s), and the financial model for the contracted services. 

Best Practice Case Studies – Addressing Nutrition, Food Insecurity, and Health Related Social Needs

ACL has worked with several partners to author a series of case studies of aging and disability network organizations addressing nutrition and food insecurity needs in their communities by braiding funding streams and forming partnerships with other organizations. Sources of funding for these efforts include the Older Americans Act (OAA), Medicare, Medicaid, and State Outreach grant funding by the Food and Nutrition Service (FNS) at the U.S. Department of Agriculture. The case studies below from Alabama and Western New York provide examples of how high-performing organizations use a variety of funding streams to address nutrition, food insecurity, and other health related social needs.

Social Care Services Evidence Summaries

These evidence summaries were developed to inform the value proposition of partnering with a CBO or a network of CBOs to offer various services and supports as part of a strategy to address health-related social needs. They are intended to complement other related evidence reviews, including those developed by the Commonwealth Fund and SIREN.

State-CBO Collaboration Think Tank: Strategic Partnerships to Strengthen Social Determinants of Health

In February – August 2021, ACL convened a State-Community Collaboration Think Tank composed of representatives from state units on aging as well as CBOs that were emerging Community Care Hubs. The states and hubs met separately and together as a larger group to explore barriers and opportunities to developing and scaling CBO networks in their states and communities. The following resources were developed as part of the Think Tank to support ongoing collaboration between states and Community Care Hubs:

Integrating Behavioral Health Supports

Integrating physical and behavioral health with social determinants of health improves outcomes at the individual, community, and population levels. Collaboration among CBOs and behavioral health treatment and recovery service providers and payers can be an effective way to achieve such integration. Developed with support from the Human Services Research Institute (HSRI), the resources below highlight evidence-based and promising practices to promote the integration of behavioral health supports into services to address any health-related social needs.

Check out these additional websites for more information and resources
Archived Resources and Webinars


In 2012, ACL funded two grants to build the business capacity of aging and disability organizations for managed long-term services and support. In 2016, ACL continued to expand the BAI by issuing three-year grants to the National Association of States United for Aging and Disabilities (NASUAD) and the National Association of Area Agencies on Aging (n4a). The grantees are working together to build on accomplishments of ACL's work. They complement other publicly and privately funded technical assistance centers that work to build business capacity in their respective networks.



Quantifying the Value Proposition: How to Calculate Return on Investment (March 9, 2016)


Network Development (February 24, 2016)


Accountable Care Organizations (October 13, 2015)


Star Ratings (September 15, 2015)


Creating Sustainable Solutions to Social Problems Through Social Enterprise (August 13, 2015)


HEDIS Measures (July 22, 2015)


Medical Loss Ratio (June 25, 2015)


Tools for Building Housing and Health Care Partnerships (May 15, 2015)


Organizational Culture Change (April 2, 2015)


Rate Determination (November 19, 2014)


Home and Community-Based Services Brokerage Guide (November 6, 2014)


Data Driven Decision Making: Nutrition’s Role in the Changing Health Care Environment (October 8, 2014)


Community-Based Organization Impact on Health System Quality and Performance Measures (April 2, 2014)


Legal Issues related to Network Formation and Business Operations (March 11, 2014)


Network Models for Integrated Care Partnerships (January 29, 2014)


Perspectives from an Accountable Care Organization and a Health Plan (July 16, 2013)


Personal Stories—Moving into a Business Market Approach (Jun 19, 2013)


TIM Talks Webinar Archive

ACL’s Office of Nutrition and Health Promotion Programs (ONHPP), in collaboration with consultant Tim McNeill, hosted a Business Acumen webinar series for CBOs entitled TIM Talks. The webinars featured discussions on various business acumen related topics in an inviting question and answer format and are helpful for all CBOs to review on a regular basis.

“Business Acumen Overview and Comprehensive Care for Joint Replacement”, April 12, 2016


“The Role of Accreditation as a CBO Business Strategy Option”, November 15th, 2017


“Care Management – The Build vs Buy Discussion”, September 28, 2017


“Chronic Care Management (CCM) - Moving from Planning to Implementation”, June 22, 2017


“Developing the Business Case for Outsourcing Care Management to a Community Based Organization (CBO)”, May 31, 2017


“Establishing CBO-Physician Collaborations to Implement Reimbursable Chronic Care Management Services”, March 30, 2017


“Health IT Interoperability and the Community Based Organization (CBO)”, January 31, 2017


“Increased Reimbursement for Care Coordination and the Potential Impact on Community Based Organizations (CBOs)”, December 21, 2016


“Developing Meaningful partnerships with Physician Practices”, October 25, 2016


“Developing Meaningful Partnerships with Hospitals”, September 27, 2016


“CMS Proposed Rule Changes and the Role of the CBO”, August 23, 2016


“Becoming a Medicare Provider”, July 19, 2016


“Engaging Managed Care Organizations (MCOs)”, June 21, 2016


“Where Do I Begin”, May 17, 2016


Last modified on 07/19/2024

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