Working With Community Care Hubs to Address Social Drivers of Health

Health Highlights

Health and well-being require far more than medical care. Research shows that personal behaviors, physical environments and socioeconomic factors—commonly referred to as social drivers of health (SDOH)—are responsible for 80 percent of health outcomes.1 Individuals enrolled in Medicaid experience disproportionate rates of complex health and social needs. With this in mind, state Medicaid agencies are increasingly looking beyond the health care system for community-based solutions to improve health outcomes.2 Community-based organizations (CBOs) are emerging as critical partners in state efforts to address SDOH.3, 4 Trusted by the communities they serve, CBOs have deep relationships, knowledge of the local environment and critical expertise in the delivery of social care. Despite their promise, challenges around the establishment and sustainability of relationships between CBOs and health care organizations5 persist, reflecting the different histories, institutions, cultures, business practices and funding streams of today’s siloed health and human services infrastructures. Community Care Hubs (CCHs) are community-centered entities that organize and support networks of CBOs to meaningfully and efficiently integrate CBOs and the health-related services they provide into the health care continuum. CCHs can ease the implementation burden that would otherwise come with ad hoc partnerships between CBOs and health care organizations, offering core functions, including developing and maintaining a network of CBOs, advancing a collective vision for CBO-health care partnerships, centralizing administrative and operational infrastructure, and managing financial resources.

Several state Medicaid agencies are currently partnering with CCHs to achieve their health and health equity goals, including:

  • Washington leveraged 1115 waiver authority to support nine regional “Accountable Communities of Health” (ACHs) originally established through a CMS State Innovation Grant to address regional health and social needs and implement the Delivery System Reform Incentive Payment program. ACHs coordinate across local communities and the health care delivery system on specific health care and social needs-related projects to improve the health of their communities as a whole. 
  • North Carolina’s 1115 waiver-authorized “Healthy Opportunities Pilots” is testing the impact of SDOH interventions on health outcomes and costs and relies on three regional CCH entities called Network Leads. Medicaid managed care plans must contract with the Network Leads, which have each developed a CBO network that provides social services to eligible Medicaid enrollees. 
  • Ohio’s baseline managed care contract requires plans to provide pregnant members with specialized services—including care coordination that links the member to needed employment, housing, education, and social and medically necessary services—through community health workers or public health nurses at qualified community hubs. 

Some U.S. Department of Health and Human Services (HHS) agencies are also advancing major SDOH and health equity strategies through CCHs. For example, in November 2022, the Administration for Community Living (ACL)—in partnership with the Centers for Disease Control and Prevention (CDC)—launched the Community Care Hub National Learning Community, which includes 58 hub participants from 32 states. On the heels of this announcement, coauthors from HHS, including ACL and CDC, published “Improving Health and Well-Being Through Community Care Hubs” on the value of CCHs and the various opportunities to leverage federal supports for their launch and operation.

In November 2022, Manatt Health released “Working With Community Care Hubs to Address Social Drivers of Health: A Playbook for State Medicaid Agencies” in collaboration with the Partnership to Align Social Care with support from The SCAN Foundation. This playbook is intended to be a resource for state Medicaid agencies seeking to partner with CCHs in the design and implementation of SDOH initiatives. The playbook offers an introduction to the key functions of CCHs and practical advice on how state Medicaid agencies can collaborate with CCHs to:

  1. Engage Communities: State Medicaid agencies and CCHs can work together to build buy-in and trust with CBOs and community members and gather feedback from a diversity of voices to inform state SDOH efforts. 
  2. Expand Community Capacity: State Medicaid agencies can collaborate with CCHs to expand the capacity of both CCHs and their affiliated CBOs to ensure their readiness to deliver social services on scale and in alignment with the service goals of state SDOH initiatives. 
  3. Support Operational Excellence: State Medicaid agencies can leverage CCHs to help establish the infrastructure and business practices required to bridge the gap between health and human services organizations in order to promote efficiency and accountability between partnering organizations. 
  4. Create Pathways to Financial Sustainability: Working with CCHs, State Medicaid agencies can help promote the sustainability of partnerships between social service and health care organizations. CCHs can provide valuable input to ensure appropriate and equitable payment rates for CBOs; help leverage funding, expertise and infrastructure from other federal, state, local and private organizations; and support evaluations that demonstrate the value of the partnerships. 
  5. Look Upstream: While seeking to address SDOH and health equity, state Medicaid agencies have an opportunity to contribute to larger collective efforts to invest in the communities in which they operate. With their diverse network of CBOs and partners in the community, CCHs can help state Medicaid agencies and other federal, state and community partners come together on community revitalization and reinvestment efforts, implement strategies to promote a robust and diverse workforce, and mobilize a variety of financial resources and advocacy efforts to improve the broader ecosystem in which these SDOH initiatives operate. 

Accompanying the release of the playbook, Manatt hosted a webinar featuring a discussion with Medicaid, health plan and CCH representatives sharing their on-the-ground experiences. Taken together, the playbook and webinar provide practical insights on the role CCHs can play to bring to scale relationships between health care and human service organizations, and real-world examples and tools of CCHs serving Medicaid enrollees today. Working with CCHs—or helping to form new CCHs—requires investment of time and resources. However, when well executed, the CCH model holds promise for supporting state Medicaid agencies to effectively and sustainably deliver whole-person care.

1 County Health Ranking Roadmaps. County Health Ranking Models. Available here.

2 Ferguson, M. and Newman, N.. The Role of Medicaid in Addressing Social Drivers of Health: MCO Community Investment Requirements. Manatt Health. October 2021. Available here.

3 Miller, E., Nath, T. and Line L.. Working Together Toward Better Health Outcomes. Partnership for Healthy Outcomes. June 2017. Available here.

4 Center for Health Care Strategies and Nonprofit Finance Fund. Advancing Partnerships between Health Care and Community-Based Organization to Address Social Determinants of Health: Executive Summary. August 2018. Available here.

5 Note: For purposes of this Playbook, health care organizations include but are not limited to: managed care organizations, accountable care organizations, hospitals, health systems and other types of provider organizations.



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