Community-based organizations (CBOs) are critical partners in state efforts to improve health outcomes. As trusted community entities, CBOs are uniquely positioned to understand community members’ needs and provide necessary services. As states pursue strategies to improve health, partnerships with CBOs — which deliver critical services to address non-medical needs — are becoming increasingly important.

In recent years, the number of CBOs contracting with health systems and managed care organizations (MCOs) has grown. However, creating the infrastructure to enable these partnerships can be resource-intensive, costly, and time-consuming for all parties. In response, CBOs are forming networks — often led by a backbone organization called a community care hub (CCH) — to establish shared infrastructure and a systematic approach for MCOs, providers, and CBOs to coordinate service delivery and referrals, as well as streamline contracting and payment. These CBO networks vary, with some operating in specific regions (e.g., local or statewide) or serving specific populations (e.g., older adults or families with children with special health care needs), while others address specific issues (e.g., housing instability or food insecurity).

Several state Medicaid programs have incorporated CCH models into their delivery systems to better align social and health care services as a way to achieve greater scale and efficiency. This brief, developed by the Center for Health Care Strategies (CHCS), examines community-based models in New York, North Carolina, and California. Drawing from these state approaches, it outlines core design and implementation approaches for establishing effective CCHs, including network lead selection, definition of core functions, data infrastructure, governance, and strategies for scaling regionally or statewide. The profiled states participate in the Medicaid Health-Related Social Needs Implementation Learning Series, led by CHCS and made possible by Kaiser Permanente through its National Community Benefit Fund at the East Bay Community Foundation.

Background on Community Care Hubs

CCHs have their roots in the aging and disability sector. Area Agencies on Aging, state-designated entities that coordinate and provide services for seniors, have long acted as CCHs by developing networks of service providers and connecting community members to needed services. With support from the Administration for Community Living, Area Agencies on Aging and similar organizations have expanded and formed CBO networks, streamlining contracting between health care and CBOs to deliver services more effectively and efficiently. Since then, numerous initiatives have evolved to test and scale CBO network models. These include the Partnership to Align Social Care, Pathways Community Hubs, the Centers for Medicare & Medicaid Services’ (CMS) Accountable Health Communities (AHC) Model, and emerging state-based efforts in California, Michigan, New York, North Carolina, and Washington State, among others.

CCHs serve as a single point of contact for health care and CBO partners, centralizing administrative functions, operational infrastructure, and business development. Known by various names — including network lead entity, bridge organization, social care network, or backbone organization — CCHs create efficiencies for CBOs and MCOs, enabling MCOs to more easily contract with multiple CBOs. While CCH models vary, they typically support common functions such as contracting with MCOs, billing and payment operations, screening and referral processes, program fidelity, technology connections, data collection and reporting, and training to meet compliance requirements such as HIPAA.

Recent research suggests that these networked models are effective at identifying community members’ health-related social needs (HRSN) and improving health outcomes. A 2024 evaluation of CMS’ AHC Model found that when community organizations provided navigation services to Medicare and Medicaid beneficiaries to address HRSN, there was a reduction in emergency department visits, inpatient admissions, and total care expenditures.

Select State Community Care Hub Models

Several state Medicaid agencies have implemented CCHs as a core component of their broader efforts to improve health outcomes. This section reviews emerging and established CCHs in New York, North Carolina, and California outlining organizational structure and services for each. Insights are based on public information, interviews with state staff, and lessons from the Medicaid Health-Related Social Needs Learning Series participants.

New York: Social Care Networks

The New York Health Equity Reform 1115 waiver amendment, approved in January 2024, invests in health through several initiatives, including Social Care Networks (SCNs), which enhance social care services for Medicaid members. SCNs build on lessons from the state’s prior 1115 waiver, where New York State Department of Health (NYS DOH) learned that health care systems did not have the capacity to contract with individual CBOs to deliver covered services to the state’s Medicaid population. Likewise, under the earlier waiver, it was difficult for individual CBOs to contract with MCOs.

To create a more effective approach to care delivery, NYS DOH created SCNs to coordinate the delivery of clinical, behavioral, and social care for Medicaid members. Within the SCN, CCHs, referred to as Lead Entities (LEs), anchor New York’s broader vision for integration (Exhibit 1). As the backbone organization, LEs must: (1) build regional networks of social service providers; (2) pay providers for delivering HRSN services; (3) ensure secure data exchange for screening/navigation; (4) report on network performance to support access and impact; and (5) establish a governing board that reflects regional needs.

To participate in the SCN, LEs are required to become Medicaid billing social care providers through an application process. Designated LEs can: (1) contract with MCOs to identify eligible members; (2) receive per member, per month (PMPM) payments from MCOs for services; (3) ensure fee scheduled-based payments to providers/CBOs; (4) track screening and referrals; and (5) maintain Medicaid billing provider status, subject to approval every five years. MCOs pay the LEs a state-defined PMPM. LEs, in turn, pay CBOs for services using a fee schedule developed with the state. To support the transition to value-based payment, LEs can earn up to 10 percent of infrastructure funding in year two and 15 percent in year three based on performance. Year-one baseline data will inform targets for subsequent years.    

In early 2025, New York named the United Hospital Fund (UHF) the Health Equity Regional Organization (HERO), a statewide coordinator bringing public health and social service organizations together in each region. UHF will analyze patient and service data to address areas of concern, such as assessing data capabilities and providing technical support. It will also collaborate with community partners to identify service gaps, evaluate impacts on health equity, and inform future advanced value-based payment arrangements aimed at reducing disparities.

Services

CBOs and other HRSN providers participating in New York’s SCN are responsible for screening and identifying eligible members. Members can also self-screen through the SCN website. SCNs offer two levels of care: (1) screening and navigation for all members (Level One); and (2) intensive support for members with unmet HRSN who meet Enhanced Population criteria (Level Two). Level Two enrollees receive comprehensive care coordination and services, including enhanced case management; housing, nutrition, and transportation supports; and respite care.

North Carolina: Healthy Opportunities Pilots*

Launched in 2021 as part of North Carolina’s transition to managed care, the Healthy Opportunities Pilots (HOP) were developed by the North Carolina Department of Health and Human Services (NCDHHS) to improve clinical and social care coordination and test the use of Medicaid to address members’ HRSN. HOP includes CBOs that are overseen by CCHs, referred to as Network Lead (NL) in North Carolina. Specific HOP goals include:

• Ensure members can access HOP services in a timely manner and in ways that meet their needs and improve their health;
• Drive equity across all aspects of the HOP program, including participation by Medicaid members, as well as CBOs; and
• Strengthening community capacity to provide high-quality, member‑centered services.

A recent HOP evaluation showed a statistically significant impact on health outcomes and cost savings. HOP enrollees experienced fewer emergency department visits and, for non‑pregnant women, a reduction in inpatient hospitalizations. According to the evaluation, NCDHHS spent approximately $85 less per HOP enrollee per month on medical and HOP services, and the longer a person was enrolled in HOP, the greater the reduction of risk and cost savings.

NCDHHS selected three HOP NLs through a competitive request for proposals. Eligible applicants included multi-service agencies, community health centers, health foundations, associations, county-based public agencies, local health departments, and social service agencies capable of serving multi-county regions. Prepaid health plans (contracted MCOs or a provider-led entity that operates a capitated contract for the delivery of covered services), MCOs, and large hospital and health systems were ineligible, unless a hospital or health system could attest to being “exclusively positioned” to serve as an NL. HOP services are reimbursed through fee-for-service or cost-based reimbursement (up to a capped amount), bundled payments, or a PMPM payment. In partnership with CMS, NCDHHS developed a fee schedule for HOP services, detailing service types, duration, unit of service/payment, and rate caps. Reimbursement also covers administrative costs.

Services

To receive HOP services, members must live in a defined pilot region (see Exhibit 2) and meet at least one needs-based criteria and one social risk factor. Members enrolled in managed care and fee-for-service are eligible. MCO care managers assess Medicaid members’ unmet social needs using a standardized screening tool covering four domains: food insecurity, housing instability, transportation, and interpersonal violence. They are responsible for screening and connecting members to appropriate CBO services. Each NL must contract with CBOs to provide 29 CMS-approved services across five areas: housing, food, transportation, interpersonal violence, and toxic stress. NLs are also responsible for supporting the CBO network, by providing technical assistance, conducting quality improvement efforts, distributing capacity-building funds to CBOs, and collecting and reporting data to support state evaluation.

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*As of June 2, 2025, the North Carolina General Assembly is considering House and Senate budget bills that do not include funding for HOP. The outcome of the 2025 -2027 Biennial State Budget negotiations could change projected funding for HOP service delivery. As a result, there may not be funding for distribution to health plans for HOP services beginning July 1, 2025.

Exhibit 2. Healthy Opportunities Pilot Regions

Building Effective Community Care Hubs

CCHs can help streamline the infrastructure between health care and CBOs to more efficiently identify member needs and deliver HRSN services. The following section outlines key design approaches for creating effective CCHs. It draws from publicly available literature and interviews with state leads overseeing CCH models within broader HRSN initiatives.

Defining CCH Functions and Operations

States can take a prescriptive approach or allow more flexibility in key CCH features, such as CCH functions, screening and navigation processes, payment and data collection. In general, however, CCHs are required to perform and oversee a typical set of core functions (see Exhibit 3).

Define CCH Functions. North Carolina directs their NLs to define their geographic service region (must include at least three counties); establish and oversee the network of CBOs; assess CBO performance; provide technical assistance and conduct quality improvement activities; oversee referral coordination and follow-up for members; and collect and submit data to NCDHHS for evaluation and oversight. For the SCN, NYS DOH created online guides for HRSN service providers and health care providers, which outline CCH functions and expectations, as well as requirements for receiving reimbursement. 

Ensure Diversity of CBOs. North Carolina and New York have encouraged CCHs to engage with community-serving providers, particularly smaller and less-resourced CBOs. New York directed its LEs to prioritize CBOs with operating budgets of less than $5 million to include smaller, locally based CBOs and ensure culturally competent service delivery, and specified that a minimum amount of capacity-building funds be allocated to smaller CBOs. Similarly, NCDHSS built requirements into their agreements with the NLs that they prioritize partnering with local CBOs to encourage smaller CBO participation.

Standardize Tools and Contracts. To standardize CCH implementation, North Carolina developed model contracts to support NL-MCO and NL-CBO contracting. New York made available model contracts for LE-MCOs and LE-CBOs, although did not require their use. New York provided these samples to support the statewide and rapid rollout of the model under the waiver timeframe.

New York requires HRSN providers to use the state’s standardized version of CMS’ AHC Screening Tool. The tool assesses member needs in several domains, including housing and related utilities; food security; transportation; employment; education; and interpersonal safety. SCN LEs coordinate with CBOs and other social and health care providers in the network to screen members at least annually using the AHC tool. 

NCDHHS developed its own standardized social determinants of health screening (SDOH) tool, which focuses on food, transportation, housing/utilities and interpersonal violence. The SDOH screening tool is built into NCCARE360, the state’s statewide screening and referral platform, and is used by health plan care managers on an annual basis with their members. 

Provide Infrastructure and Capacity Building Support. As part of North Carolina’s 1115 waiver approval, CMS authorized $650 million in Medicaid funds over five years to implement HOP. Of the total funding, North Carolina designated $100 million for infrastructure development and CBO capacity building, half of which must be used to strengthen CBOs. After initial HOP capacity-building funds run out, NLs will receive an annual administrative budget from NCDHHS.

Maximum infrastructure funding per SCN varies by region, based on Medicaid member volume and HRSN service costs. LEs have flexibility in how they allocate capacity-building funds to CBOs and other partners. Guidelines for the appropriate use of infrastructure funding and HRSN screening and service funding are outlined in SCN Program, Billing, and Data Governance Operations Manual.

Across both states, infrastructure funds can be used to cover core staff; administrative and indirect costs; IT systems; and CBO capacity-building efforts such as preparing community providers to deliver services and receive payment, program monitoring, technical assistance and ensuring program integrity.

Competitively Selecting CCHs

States will want to assess core characteristics and capabilities of CCHs to ensure they are able to effectively develop and manage a network of social and health service providers. Both New York and North Carolina defined the essential functions the CCHs should be able to perform and competitively procured community organizations to oversee the administrative and operational functions of their broader network of community-based providers.

Develop CCH Requirements. NCDHHS developed a set of scoring criteria for NLs that included background and experience working within their respective communities, geographic region, financial stability, capacity for and experience convening community stakeholders. Organizations eligible to apply through a competitive selection process included multi-service agencies, community health centers, community health foundations, associations, county-based public agencies, local health departments, and social service agencies that can effectively serve a multi-county region. As noted earlier, prepaid health plans, MCOs, and large hospital and health systems were ineligible to serve as NLs (an exception is made for hospital and health systems that are “exclusively positioned” to serve as the NL). NLs must also adhere to cultural competency standards to maintain strong connections with the communities they serve and ensure that the NL’s staff understand the community’s background, demographics, and HRSN of the communities they serve, including members of federally recognized tribes.

Entities eligible to serve as LEs in New York include independent practice associations, Medicaid health homes, behavioral health collaboratives, federally qualified health centers, or performing provider systems. LE applicants were required to have at least three years of experience contracting with, leading, and administrating CBOs in their region, and vast knowledge of community needs and available resources.

Determining Data Infrastructure and Sharing

A robust data infrastructure is critical to support screening and referrals, monitor CCH activities, and demonstrate effectiveness. States stressed the importance of collecting quality data to identify gaps, trends, and outcomes, though they took varied data collection and sharing approaches.

Create a Statewide Platform. North Carolina requiresNLs to use NCCARE360, the state’s centralized platform for screening and referral. NCCARE360 uses Unite Us as the technology vendor and includes the United Way of North Carolina and NC 211 as key partners. While originally launched as part of HOP, NCCARE360 is now used statewide to connect individuals to needed community services. Advanced features, including invoicing, payment processing, and eligibility determination, are reserved for HOP NL use.

The expansion of HOP statewide created some challenges around training a wide range of CBOs with various levels of technological sophistication, and fine-tuning the platform to meet the needs of health care organizations, prepaid health plans, and the CBOs. To ensure CBOs are able to participate in CCH models, states can consider developing a CBO readiness guide to help community organizations assess their capacity to use technology platforms and meet required data collection and sharing expectations. Ensuring there are local technical assistance providers who understand the community context and can provide technical support related to data-sharing to community organizations can facilitate success for CBOs.

Use a Flexible Approach. New York allowed SCN LEs to build or purchase their own screening and referral platforms (i.e., Unite US, Find Help, Channel 360, and Together Now). New York permitted this flexibility because of their preexisting Statewide Health Information Network for New York (SHIN-NY), which enables data sharing statewide and allows referral and social care need data to feed into SHIN-NY. While the state covers the cost of SHIN-NY connectivity, LEs are responsible for paying for the individual screening and referral platforms they use. Data from these platforms are processed through SHIN-NY and are aggregated to provide a single statewide data warehouse. Screening can also be done by health care providers within their electronic health record systems and sent through the SHIN-NY and pulled into the respective SCN platform. NYS DOH created standardized codes for all screening and services to allow for data tracking and aggregation across SCNs.

Scaling CCH Models

Implementing CCH models requires coordination across a variety of stakeholders, including health and social care providers, state and local governments and community members. States should have processes in place to identify provider challenges, program gaps, as well as model effectiveness.

Pilot Test Models. North Carolina launched its HOP model in 33 out of the state’s 100 counties before expanding to all counties under the waiver renewal. This scaled approach allowed NCDHHS to incorporate lessons learned on building CBO capacity, adapting the NCCARE360 platform to serve all users, and making refinements to service offerings. While launching 28 of the 29 identified services created a significant administrative burden for providers, it also enabled the state to identify which services were in high demand and which services were less used. New York, conversely, launched its SCN initiative statewide, which required extensive coordination among health care providers, CBOs, and government agencies.

Engage in Continuous Improvement. North Carolina and New York are conducting both rapid cycle and long-term evaluations to inform data-driven modifications and expansions of their programs in the years ahead. New York launched the Health Equity Regional Organization (HERO) Initiative to integrate public health partners in each SCN region of the state through a cross-sector approach. HERO will also develop and evaluate success metrics related to the SCNs and identify regional gaps, as part of a greater evaluation of the state’s 1115 waiver. North Carolina is using rapid cycle assessments in addition to yearly evaluations to obtain real-time data and enable improvements along the way.

Establishing Governance Models

CCH advisory boards, often comprised of a diverse range of community members and stakeholders, play an important role guiding CCH strategy and care delivery, and support operational decision making across the network. Engaging Medicaid members and CBOs on these advisory boards ensures that programs and policies reflect community needs.

NCDHHS requires that HOP NLs convene a governing body to oversee NL program-related activities and the use of pilot funds. The governing body is required to include representatives from health and social care sectors, including Preferred Health Plans, health systems, local health departments, behavioral health care providers, federally qualified health centers, rural health clinics, and human services organizations, as well as other community stakeholders such as philanthropy, associations, state and local governments, consumer advocates (including current or former Medicaid members, their guardians, or caregivers), and at least one member with evaluation and data management experience. While not a requirement, NCDHHS also encourages the inclusion of a representative with experience in network development to further strengthen the advisory board’s capacity.

New York’s SCN LEs are governed by an oversight board, which must be comprised of CBOs (51 percent), health care providers (including at least one mental health and substance use disorder provider), community advocates, and at least two current Medicaid members who are receiving HRSN services (or have in the past). Although it is still early in the implementation process, New York is hopeful that prioritizing the community perspective will enhance effectiveness.

Conclusion

Every state approaches this new coordination of work across the medical and social sectors in a nuanced way, leveraging the strengths of their specific environments to best meet the needs of the Medicaid population. CCHs provide a promising mechanism to streamline this coordination, allowing individuals to access local resources to achieve better health while meaningfully supporting local economies.