Annual Report 2023: Building bridges between social care and health systems


This story first appeared in our 2023 annual report.

“I’ve always believed that social workers and community groups had an important place at the table as part of the medical care team.”

~ Nora OBrien-Suric, President of the Health Foundation for Western & Central New York

Nationwide, between 2017 and 2021, the percentage of community-based organizations contracting through a network doubled—from 20% to 40%.

Source: Scripps Gerontology Center, Miami University

Shifting mindsets around social care

In 2010, the passage of the Affordable Care Act (ACA) accelerated a growing movement in health care: the recognition that social determinants of health—factors that affect people’s lives like access to food, housing, or transportation—can play a key role in health outcomes.

As part of this paradigm shift, health insurers and traditional health systems were encouraged to begin contracting for services with community-based organizations (CBOs) that provide social care.

The change presented an opportunity for CBOs to create more sustainable business models, build greater collaboration, and access new funding opportunities—not to mention work toward better health outcomes for the people they serve. But it also put strain on small organizations that lacked the time, staff, and resources to take on the administrative needs required by these new relationships, such as billing and contracts.

These challenges led to the creation of Community Care Hubs (CCHs), networks that ease the burden of doing business on participating social care organizations by providing shared access to services like billing, reimbursement, marketing, information technology, and more.

The CCH framework makes collaboration between social care organizations and health systems more cost efficient and streamlined on both sides, incentivizing new partnerships.

Health Foundation President Nora OBrien-Suric, Ph.D., was an early champion of this approach dating back to a previous role with The John A. Hartford Foundation. Under her leadership, the team at the Health Foundation has continued to advance programs and partnerships that encourage this approach to collaboration.

“We’ve always known that bringing ideas and groups together is the way to foster new solutions, especially for holistic health care,” said Nora.

Today, Community Care Hubs are a growing force in 21st century care delivery.

Today’s Community Care Hubs

As the CCH model becomes more widely used around the country, the Health Foundation is supporting CCHs in our communities: Western New York Integrated Care Collaborative (WNYICC), headquartered in Buffalo and serving western New York, and Inclusive Alliance, headquartered in Syracuse and serving central New York. The two Hubs also belong to the National Learning Community (NLC) for Community Care Hubs, which allows them to tap into a broader network for deeper professional development and share resources more widely.

Breaking down silos

“We’re always looking at it from the CBO perspective. How can we keep their administrative burden as low as possible so they can focus on people?”

Nikki Kmicinski, Executive Director, Western New York Integrated Care Collaborative

WNYICC (pronounced win-ee-ick) grew out of a Health Foundation program called Ready or Not. The program helped organizations build capacity and adapt to the economic and regulatory changes having an impact on health care at both the state and federal level.

Today WNYICC’s network includes eight Area Agencies on Aging (AAA), one Center for Independent Living (CIL), two county health departments, and more than 55 nonprofit community-based organizations (CBOs). Executive Director Nikki Kmicinski describes WNYICC as the network’s administrative backbone.

WNYICC was one of the first 12 in the country to be funded through the U.S. Administration for Community Living, and in November 2023, one of six from across the country to be profiled in Community Care Hubs: A Promising Model for Health and Social Care Coordination, a report released by the U.S. Department of Health and Human Services. WNYICC was highlighted for its ability to work directly with CBOs to provide vital services, such as hospital-to-home transition support, as well as meals and food security.

In 2023, WNYICC also secured a first-in-the-nation contract with a Medicare Advantage plan for a program called Health Coaching. The program earned WNYICC a Business Innovation award from The John A. Hartford Foundation.

How do CCHs help people in our community? Nikki describes an older adult who needed help with meals. The man agreed to work with a dietitian after receiving a referral to a nutritional therapy program. He confided to the dietitian that he was prone to falling. The dietitian enrolled him in a fall prevention program, which helped him improve his strength and balance. Some fall-proof adjustments were made to his home, too. There was no need for permission from the man’s health insurance plan to move him into these programs. The insurer had complete trust in WNYICC’s ability to assess their client’s needs, make the appropriate referrals, and integrate health and social care effectively.

“This gentleman can now live independently longer, compared to if he had not gotten the support,” Nikki says.

Helping the helpers

“Community Care Hubs tap into new funding streams that allow CBOs to enhance, expand, and strengthen their ability to reach folks in need and do that connecting work.”

~ Lauren Wetterhahn, Executive Director

One benefit of this approach is that no two CCHs look exactly alike. Instead, they are created to meet their community’s unique needs.

Inclusive Alliance, a central New York-based CCH, is tailored to serve the region through its network of over 50 CBOs. In 2023, the Health Foundation provided funding to help Inclusive Alliance build and strengthen its technical infrastructure, including data storage.

Network Development Manager Nicole Hall describes the Hub’s new data warehouse for social care services. Her team can see how many people are being served by organizations across counties, as well as the type and breadth of available services. Eventually, this information will be overlaid with census data to uncover additional insights, like service overlaps and coverage gaps.

“We’re engaging with those smaller grassroots organizations and trying to elicit the data from them that they haven’t been able to showcase well before. Then we can demonstrate their impact across the community,” Nicole explains.

CBOs deserve to be compensated fairly for the important care they provide, but engaging with health insurers and public payers can be complex. To support them, a CCH like Inclusive Alliance guides CBOs on what billing for work entails, whether it’s Medicaid reimbursement for doula services, Medicare reimbursement for physical therapy, or something else. Inclusive Alliance leverages its knowledge of new social care payment models and billing codes from the health care sector to further support CBOs.

“Being able to tell organizations that something they’re already doing could be bringing in revenue is an essential part of what a CCH can do,” Lauren explains.

Community Care Hubs offer invaluable services that will become increasingly in demand as more providers recognize how social determinants of health drive key outcomes. The Health Foundation is proud to have been at the forefront of supporting this transformative care delivery approach. We’ll continue to collaborate with our network of community organizations and help them strengthen their ability to innovate, collaborate, and meet the needs of our communities.