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Working With Community Care Hubs to Address Social Drivers of Health

December 19, 2022Elizabeth Osius, Natassia M. Rozario, Justine Zayhowski Segal, Melinda J. DuttonManattSocial Determinants of Health (SDOH),Community Health Solutions

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. 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. Community-based organizations (CBOs) are emerging as critical partners in state efforts to address SDOH. 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 organizations 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.

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