Improving Health And Well-Being Through Community Care Hubs

As part of the Department of Health and Human Services’ (HHS’s) strategic approach to addressing social determinants of health (SDOH), we envision a future in which all individuals, regardless of their social circumstances, have access to aligned health and social care systems that achieve equitable outcomes through high-quality, affordable, person-centered care.

While identifying pathways to adequately fund social care is critical to achieving this vision, there is also a need for communities to develop sustainable partnerships among health care providers, the public health system, and community-based organizations (CBOs), and to develop the data and financing infrastructure needed to support these partnerships. Multistakeholder collaborations to address SDOH have flourished in recent years and have informed what is needed to develop a sustainable operating infrastructure between health care and CBOs to address health-related social needs. This infrastructure is increasingly provided by community care hubs (hubs)—community-focused entities supporting a network of CBOs providing services addressing health-related social needs—which centralize administrative functions and operational infrastructure. Hubs can benefit from multistakeholder community governance and planning, similar to what occurred in a number of the accountable health community model implementations. These efforts can help identify sources of financing that can support care coordination and service delivery, as well as ensure that multiple perspectives are heard and incorporated when making decisions about how best to screen, manage referrals, coordinate care, and deliver services. This includes ensuring referral technology platforms and workforce are used in a coordinated and equitable manner. Hubs, also referred to as backbone organizations, can include governmental as well as non-governmental organizations as funders, participants, and in some instances as conveners. They can also collaborate with local public health authorities to ensure that community population health strategies addressing SDOH are coordinated.

Here, we discuss the role and functions of hubs, provide examples of these organizations, and explore policy opportunities to maximize their role.

Role And Functions Of Community Care Hubs

Hubs can provide the connective tissue within a community to ensure that a coordinated system of health and social care is working equitably to meet an individual’s needs. A lead entity managing the hub operates an overarching structure to support other members by centralizing administrative functions and offering a single point of contracting for health care providers and payers. Given growing recognition of the role of health-related social needs in affecting health outcomes and new flexibilities in payment policy that are allowing for reimbursement of social care needs in certain circumstances (as discussed further below), health care organizations have been increasingly contracting with CBOs across the country over the past five years and some of these CBOs may have the capacity to act as hubs in their communities.

Exhibit 1 provides a conceptual model of processes hubs can help to support. Beyond these processes, hubs can also:

  • Coordinate funding from multiple private and public sources to develop hub infrastructure.
  • Leverage trusted relationships and members’ existing assets including workforce, service delivery expertise, and cultural competency to coordinate care in collaboration with health care partners.
  • Offer a single point of contracting for CBOs of all sizes with health care entities.
  • Enable CBOs and the communities they serve to have a seat at the table with health care providers in communities where underresourced CBOs may not otherwise be included in decision making.
  • Coordinate community-based workforce development and training.

Exhibit 1: Community care hub conceptual model

Source: Authors’ analysis.

Existing Community Care Hubs

Hubs are growing in number across most states and supported by a variety of funding and policy mechanisms. Research indicates that hubs can improve coordination and continuity of care, data-sharing capabilities, and the ability of CBOs to address health-related social needs. In states such as Alabama, Arizona, California, Massachusetts, New York, Ohio, and Virginia, hubs have partnered with health care organizations to improve the lives of the individuals they serve. Three examples of hubs funded through HHS programs are described below.

The Western New York Integrated Care Collaborative (WNYICC) is composed of more than 30 CBOs serving individuals of all ages in western and central New York and partners with health care plans and providers to improve patients’ health. In 2020, WNYICC contracted with a regional Medicare Advantage plan to provide post-discharge home-delivered meals and incorporated patient satisfaction surveys to facilitate feedback to the health plan. After a successful proof-of-concept, their contract was expanded to include services including chronic care management, an expanded meal benefit, and a social isolation intervention. WNYICC also works with Medicaid managed care organizations (MCOs) and entities participating in the Global and Professional Direct Contracting Model to help connect beneficiaries with health-related social needs with social care providers participating in the Collaborative. One member of the Collaborative, LifeSpan, received health care referrals for more than 1,200 older adults between 2016 and 2019 and connected them with an average of four community-based services, which was associated with a 29 percent reduction in inpatient hospitalizations and a 28 percent reduction in emergency department visits.

The Alameda County Care Connect Initiative is a California Medicaid (Medi-Cal) Whole Person Care Pilot that began operating in 2016 through a Medicaid Section 1115 demonstration, designed to coordinate physical health, behavioral health, and social care for high-cost, high-need enrollees. Working with multiple county agencies, eight community partners, and two managed care plans, the Alameda initiative is promoting increased integration and person-centered care across all types of providers. The program includes funding for housing assistance, implementation of a community health record data-sharing system, improvement of care coordination, investment in training and sustainability, and expansion of substance use disorder treatment. Based on data from 2017 to 2019, researchers found improvements in coordination and continuity of care and in data-sharing capabilities.

The Community Partners program was launched in July 2018 by Massachusetts’ Medicaid program, MassHealth, also as part of a Section 1115 demonstration. The demonstration required Medicaid accountable care organizations (ACOs) to contract with state-certified community partners. In doing so, the ACOs contracted with certified CBOs that served the hub function of being a single point of contracting for social care providers. One such Medicaid ACO is My Care Family, consisting of 16 primary care provider practices serving more than 40,000 culturally diverse members (70 percent of whom identify as Hispanic). The Medicaid ACO contracted with Merrimack Valley Community Partner (MVCP) a partnership between AgeSpan and the Northeast Independent Living Program (a peer-run independent living center providing services to people with disabilities). MVCP assigns a care coordinator to work with members and their health care providers to create care plans that support member goals. They are focused on increasing childhood immunization, asthma medication adherence, provision of comprehensive diabetes care, and engagement in substance use disorder treatment. The initial success of the partnership led to an expansion of contracted services in 2020 to include nutrition and housing services.

Policy Opportunities To Foster The Development And Sustainability Of Community Care Hubs

The expansion of hubs can be supported through efforts by the federal government and others. For instance, work is underway to identify core competencies for hubs and establish objective standards to facilitate future credentialing of these entities. Other specific strategies to support these efforts are discussed below.


HHS currently provides funding to 12 hubs through Administration for Community Living (ACL) grants with additional funding to reach up to 20 more hubs planned during 2023. More broadly, hubs can employ a number of approaches to coordinate federal, state, local, and private funding, such as braiding and blending, to support their work in a coordinated manner. Braiding is when funding streams from different sources are coordinated, but not combined, to pay for a mix of services and functions. Blending is when multiple funding streams are pooled to fund an overall activity. Some hubs leverage funding from ACL, the Administration for Children and Families, and the Department of Housing and Urban Development (HUD) to support their functions including coordinated access to services and supports. There are also opportunities for hubs to coordinate funding to support both the workforce and service delivery across a network of CBOs. For example, a hub can finance nutritional assistance in a community, including outreach, enrollment, and home delivered meals, through a combination of US Department of Agriculture benefits, the ACL Senior Nutrition Program, Medicare Advantage supplemental benefits, and Medicaid-funded services. Federal guidance and technical assistance can help local jurisdictions identify ways to braid and blend funding. HHS has provided guidance to clarify that HHS transportation grants can provide matching dollars to Department of Transportation grants to cover the full cost of transportation for individuals. States can also play an important role by providing information on how funding from state-based programs can be combined.

Beyond federal social program funding, hubs can use other health care payments to support their functions and services, including those through Medicaid 1115 demonstrations and State Plan authority, Medicare Advantage Special Supplemental Benefits for the Chronically Ill, and the advanced investment payments for new ACOs joining the Medicare Shared Savings Program, which will permit the use of traditional Medicare funds to address social needs. Building on its Accountable Health Communities (AHC) Model that funded hubs, the CMS Innovation Center is also committed to incorporating health-related social needs screening, referral, and navigation, as well as coordination with CBOs into existing and future models. While AHC Model funds could not be used to fund social care, the CMS Innovation Center is testing offering non-primarily health-related supplemental benefits to targeted enrollees based on chronic conditions and socioeconomic status within the Value-Based Insurance Design Model.

Another potential funding source to support hubs is hospital “community benefit” spending. To qualify for nonprofit status and receive a tax exemption, in addition to meeting general Internal Revenue Service requirements for all nonprofit organizations, hospitals must conduct community health needs assessments every three years (a requirement of Section 4959 of the Affordable Care Act). Hospitals can and should partner with CBOs on these assessments intended to inform the investments hospitals will make to improve the well-being of the communities they serve (known as community benefit). Many nonprofit hospitals currently receive substantially more in tax exemptions than the total amount they spend on charity care plus investments in their community. Hospitals could use community benefit dollars to support community building efforts and fund approaches to address SDOH and health-related social needs identified in their community health needs assessments, while continuing to engage with CBOs and other partners on these implementation efforts. Beyond hospital community benefit spending, other local sources of funding that can be leveraged to support development of hubs include funding from philanthropies, employers, and municipalities.

Community Cohesion

It is critical that the approach to address health-related social needs reflects communitywide governance and planning. By incorporating input from community leaders and reflecting the demographic and lived experience of those served, the hub can ensure inclusion of local priorities, goals, and culture. Communitywide governance and planning to address health-related social needs should incorporate input from community leaders and reflect the demographic diversity and lived experience of the those served by the hub. HHS agencies, including ACL and the Centers for Disease Control and Prevention (CDC), are accelerating efforts to develop communitywide approaches to address SDOH and inequities through hubs. In November 2022, a national learning community to foster development of hubs will bring together social care, public health, housing, and health care leaders to co-design and sustain hubs. Nearly 60 organizations representing 32 states will participate, with participants representing a range of organization types, partnerships, and populations served. Through this opportunity Area Agencies on Aging, United Way, and other Accountable Health Community backbone organizations are coming together within the communities they serve to create a more cohesive communitywide approach to developing a community care hub. Complementary efforts, such as the HHS-HUD Housing and Services Resource Center, will also facilitate federal and state coordination and partnerships to improve access to housing and other social care services, which can be sustained over time through hubs. These and other resources may be particularly useful for communities that are not already involved in the work of developing or implementing CBO networks but are interested in such initiatives. Additionally, the Partnership to Align Social Care, a national learning and action network, brings together leaders across CBOs, health plans and systems, national associations, philanthropy, and federal agencies to co-design a multifaceted strategy to enable successful partnerships among health care organizations and hubs. Key to this strategy is the inclusion of community voice as a primary input, which is represented in principles the Partnership developed for an equitable health and social care ecosystem. Through collaboration and co-design, the Partnership aims to enable and support efficient and sustainable ecosystems needed to provide individuals with holistic, equitable, community-focused, and person-centered care.

Screening, Technology, And Data Collection

CMS recently adopted two new measures in the Hospital Inpatient Quality-Reporting Program to promote SDOH screening among hospitals. More broadly, health care providers, hubs, and individual CBOs can leverage existing screening tools, such as the Health-Related Social Needs Screening Tool that was used in the Accountable Health Communities Model, customizing them for their local context.

Supporting the adoption of interoperable health information technology standards can facilitate many critical hub functions including screening, referral, maintenance of a directory of community services, coordination of services, financial management, and measurement of health and social needs referral outcomes. Interoperability can be supported through the recognition of non-proprietary standards including those in the Office of the National Coordinator for Health Information Technology (ONC) Interoperability Standards Advisory, as well as the inclusion of data classes and associated data elements in United States Core Data for Interoperability (USCDI). Many federal agencies support the Gravity Project, which is developing consensus-based data standards to improve how information on SDOH can be used and shared. ACL and ONC are also funding pilot opportunities through the Social Care Referrals Challenge and the Leading Edge Accelerator Project (LEAP), and there are complementary efforts to advance interoperability for directories of social service providers. The Agency for Healthcare Research and Quality is working to facilitate the creation of primary care dashboards that use data on chronic disease, SDOH, and community services to support better management of high-risk individuals and populations.

Coordination at all levels—federal, state, and community—will be critical to realizing interoperable systems to align health and social care to improve community well-being.

Community-Based Workforce

The CDC is also supporting an expansion of the CHW workforce through grants to public health entities; public health entities play a variety of roles that support the community health workforce, including serving as providers, providing data on needs, and employing CHWs. As part of the American Rescue Plan, the Health Resources and Services Administration (HRSA) provided grants to expand community-based efforts supporting CHWs to conduct tailored local vaccine outreach, build vaccine confidence, and address barriers to vaccination. The expansion includes multiple CHWs within each of 158 funded CBOs with geographic coverage in all 50 states. The HRSA also recently launched the Community Health Worker Training Program, a multiyear program focused on on-the-job training to increase the number of CHWs connecting people to care.


Hubs provide an opportunity to effectively and equitably coordinate health care and social care to meet the needs of individuals within their communities. Developing and strengthening the connective tissue across these sectors can benefit from the concerted efforts of multiple federal programs, state, local, and tribal governments, CBOs, health care providers, payers, public health entities, and others to holistically address the needs of the populations we serve.

Authors’ Note

We thank Victoria Aysola, Lauren Antelo, Melissa Ryan, Jana Towne, and Carol Lincoln for their contributions to our joint efforts to address health and social care coordination and for providing helpful feedback on this article. Everyone who is included as a co-author is an employee of the federal government.