Strengthening Health Care Through Community-Based Organizations

Overview

Federal priorities have increased focus on the social factors that play a significant role in health outcomes. Efforts to integrate social determinants of health (SDOH) screening into health care models are ongoing, but a gap has been identified between positive screenings and outpatient referrals for services.[1] Nationally, there is a window of opportunity to build sustainable and beneficial cross sector collaboration. Effectively meeting community needs requires health care professionals and public health leaders to act now, forging improved partnerships with community-based organizations. 

Background

Recognizing the significant impact of social determinants of health on achieving health equity, the Centers for Medicare and Medicaid Services agency (CMS) has suggested that all health care organizations and providers integrate SDOH screening and care into their health care models and programs.[2] Other organizations, including the Joint Commission and the Agency for Healthcare Research and Quality (AHRQ), have made similar recommendations to health care organizations. AHRQ further suggests that community linkage with health care providers is essential to assess and improve patient care.

Medical systems are now integrating these screening processes into their health care models to identify patients and families with unmet SDOH needs that may impact their health. However, studies have identified a gap between positive screeners (when an unmet SDOH need is found) and outpatient follow up and referral contact.[3] Deloitte Center for Health Solutions reported that only about 33% of 300 hospitals and health systems had developed a system to connect patients who have positive SDOH screenings with resources or support specific to their social needs.[4] Figure 1 illustrates the survey results, which found that while most health care leaders report they are screening the patients for SDOH, fewer say they are connecting patients to services that address SDOH — whether via community partners or in-house programs.

Figure 1 — Screening Patients for SDOH and Connecting Them to Services

The Current Situation

Community-based organizations (CBO) are public or private, nonprofit organizations that serve their local community to address community needs.[5] Health care organizations that take action on positive SDOH screeners often do so by partnering with CBOs that can specifically address needs such as food insecurity, transportation assistance, financial strain and housing instability.

As screening for unmet social needs expands, referrals from clinical providers or organizations are expected to rise accordingly and “community carrying capacity” is key — this term refers to the ability of CBOs to absorb new referrals from clinical partners while continuing to meet ongoing community needs.[6]

Health care providers have historically had limited insight into the perspectives and capacity of CBOs to expand and manage referrals, while CBOs have similarly lacked understanding of the medical sector's approach. The following common themes from the literature highlight key findings.

Defining Roles and Protocols Is a Two-Way Street

CBOs reported limited understanding of how the medical sector implements social need screening and referrals. Likewise, clinical providers had little knowledge of CBOs’ operations, funding sources, and their capacity to serve referred individuals.[7] By clarifying and aligning screening and referral protocols on both sides, the potential for redundant processes can be significantly reduced.[8]

Health care organizations should: 

• Establish workflows that include regular vetting and maintenance of their community organization partnerships as well as regular check-ins with CBOs to discuss capacity.[9]
• Build a comprehensive community resource repository to ensure that alternative CBOs are available to support patients and families when one reaches capacity.[10]

Funding

The service capacity of CBOs is driven by available resources and understanding funding streams is crucial when evaluating the landscape for CBOs.

• Half of CBOs report funding as being key to “sustaining and providing services to clients.”[11]
• Studies have shown that the majority of CBOs relied upon short term funding — this can lead to gaps in service delivery, making it difficult for organizations to maintain consistent support and meet the ongoing needs of the communities they serve.[12]
• Most CBOs operate with more than one revenue stream — including federal, state, and local government grants, foundation grants and private donations.[13]
• A significant point — while health care providers are now being incentivized to screen and refer for SDOH, CBOs are not universally receiving financial incentives or reimbursement to provide their services or resources to families.[14]

Assessing Capacity and Needs for the Future

• CBOs have described a “sense of profound scarcity of resources” and many CBOs cite the challenge of coping with increased capacity demands.[15] In one study, only 10% of respondents reported being currently fully equipped to support their capacity, citing needs such as staff recruitment, data and technology infrastructure, and development of staff and coalitions.[16]   
   
• Technology infrastructure for tracking services is a critical need. A study of 75 CBOs within two U.S. metro areas found that only a small portion of CBOs had the data to assess their capacity for additional clients. About one-third monitored case load levels, service history, client outcomes, or long-term financial data.[17]   
   
• How CBOs handle referrals also needs attention. Health care organizations within a city or region may use a variety of systems to refer patients to CBOs, but most CBOs lack the operational capacity to manage referrals from multiple separate platforms. This underscores the need for a scalable model to simplify cross-sector partnerships.

Policy Recommendations

We recommend the following policies to promote closed-loop processes that effectively address SDOH needs.[18]

1. Prioritize Building Cross-Sector Partnerships

Health care organizations that successfully address unmet SDOH needs have strong relationships with the CBOs they refer to and are aware of each CBO’s capacity to provide services. It is essential to bring CBOs to the table to build these connections. Actively building sustainable cross-sector partnerships places equal emphasis and importance on both the clinical provider and CBOs and ensures that both parties receive the support they need.

One way to build these partnerships is by adopting the community care hub model (Figure 2). Community care hubs “leverage community capacity and expertise to allow for an efficient, scalable approach to health care/CBO partnerships that can facilitate care coordination and service delivery” to address SDOH.[19] Hubs can help develop and manage a network of CBOs, taking on responsibilities such as administrative functions and funding for the network. This allows “health care organizations to efficiently contract with multiple CBOs in a streamlined way through a single point of contact.”[20]

Figure 2 — Community Care Hub Conceptual Mode

2. Advocate for Federal and State Funding Opportunities 

Advocating for federal and state policy opportunities to improve funding streams for CBOs will enable strengthening of their infrastructure, operational capacity, and long-term sustainability. 

• Managed care organizations (MCO) can offer financial and technological support to build and sustain CBO capacity.
  • One approach is leveraging Medicaid or Medicare regulations to cover certain social services, through mechanisms such as in lieu of traditional medical services or Section 1115 demonstrations.[21]
  • State agencies can also provide incentives to MCOs to pilot partnership initiatives that can be scaled across participating MCOs within the state or a region.[22]
• At the federal level, advocacy for sustained sources of funding is vital. In 2023, a step was made in this direction when a $5.5 million federal discretionary grant was awarded to fund a national Center of Excellence, aimed at providing technical support and facilitating collaboration between community care hubs and the health care sector.[23]
• Health care organizations can also partner with CBOs to develop more robust grant proposals and funding submissions. Further, academic health institutions can provide technical assistance such as grant writing, study design, program evaluation, and subject matter expertise to CBOs to strengthen grant applications.

3. Focus on Coordinating Data, Advancing Technology and Interoperability

Prioritizing the development of strategies and mechanisms for data sharing and communication — especially across electronic health records platforms — is crucial. The ability to track an individual’s SDOH needs more effectively will reduce redundancy in screening and referrals, improve monitoring of long-term progress, and maintain the privacy and security of sensitive information.

• CBOs and academic health institutions can strategically partner to work on data storage, analyses and visualization. The Gravity Project is one example — its goal is to build “consensus driven SDOH data standards for health and social care interoperability and use among multi-stakeholders.”[24]
• For novel initiatives such as the Gravity Project, establishing efficacy metrics is essential to track closed-loop referrals, utilization of resources, CBO capacity, and patient outcomes.

Conclusion

Community-based organizations play an indispensable role in addressing local needs, but as screening for SDOH increases, the influx of referrals from health care organizations strains their capacity. To ensure CBOs can meet growing demands and continue positively impacting health outcomes, policymakers and stakeholders must develop policies at the national and state levels that support the expansion of CBO infrastructure. These policies should guarantee funding for services addressing SDOH, such as food and housing insecurity. Without targeted policy interventions, inequity in health outcomes and the economic consequences will persist.

Notes

[1] Social determinants of health (SDOH) is the term generally used in the literature, while in Texas these factors are often referred to non-medical drivers of health (NMDOH).

[2] Centers for Medicaid and Medicare Service (CMS), “CMS Issues New Roadmap for States to Address the Social Determinants of Health to Improve Outcomes, Lower Costs, Support State Value-Based Care Strategies,” press release, January 6, 2021, https://www.cms.gov/newsroom/press-releases/cms-issues-new-roadmap-states-address-social-determinants-health-improve-outcomes-lower-costs.

[3] Kevin Chagin et al., “A Framework for Evaluating Social Determinants of Health Screening and Referrals for Assistance,” Journal of Primary Care & Community Health 12 (December 2021), https://doi.org/10.1177/21501327211052204.

[4] Kulleni Gebreyes et al., “Addressing the Drivers of Health,” Deloitte Insights, November 5, 2001, https://www2.deloitte.com/us/en/insights/industry/health-care/drivers-of-health-equity-survey.html.

[5] Raman Nohria et al., “Community-Based Organizations’ Perspectives on Piloting Health and Social Care Integration in North Carolina,” BMC Public Health 23, art. 1914 (October 2023), https://doi.org/10.1186/s12889-023-16722-4; “Promising Practices for Reaching At-Risk Individuals for COVID-19 Vaccination and Information”HHS, Administration for Strategic Preparedness and Response (ASPR), accessed September 18, 2024, https://aspr.hhs.gov/at-risk/Pages/engaging_CBO.aspx.

[6] Laurie E. Paarlberg and Danielle M. Varda, “Community Carrying Capacity: A Network Perspective,” Nonprofit and Voluntary Sector Quarterly 38, no. 4 (April 2009): 597–613, https://doi.org/10.1177/0899764009333829.

[7] Rachel Hogg-Graham et al., “Exploring the Capacity of Community-Based Organisations to Absorb Health System Patient Referrals for Unmet Social Needs,” Health and Social Care in the Community 29, no. 2 (March 2021): 487–95, https://doi.org/10.1111/hsc.13109.

[8] Etsemaye Agonafer et al. “Community-Based Organizations’ Perspectives on Improving Health and Social Service Integration,” BMC Public Health 21, art. 452 (March 2021), https://doi.org/10.1186/s12889-021-10449-w.

[9] Patricia Peretz et al., “Social Determinants of Health Screening and Management: Lessons at a Large, Urban Academic Health System,” The Joint Commission Journal on Quality Patient Safety 49, nos. 6–7 (June–July 2023): 328–32. https://doi.org/10.1016/j.jcjq.2023.04.002: Etsemaye Agonafer et al.

[10] Department of Health and Human Services (HHS), “Call to Action: Addressing Health-Related Social Needs in Communities Across the Nation,” November 2023, https://aspe.hhs.gov/sites/default/files/documents/3e2f6140d0087435cc6832bf8cf32618/hhs-call-to-action-health-related-social-needs.pdf.

[11] Rachel Hogg-Graham et al.

[12] Rachel Hogg-Graham et al.; Etsemaye Agonafer et al.; and Lauren A. Taylor and Elena Byhoff, “Money Moves the Mare: The Response of Community-Based Organizations to Health Care’s Embrace of Social Determinants,” The Milbank Quarterly 99, no. 1 (2021): 171–208, https://doi.org/10.1111/1468-0009.12491.

[13] Rachel Hogg-Graham et al.; Etsemaye Agonafer et al.; and Lauren A. Taylor and Elena Byhoff.

[14] Domestic Policy Council, Office of Science and Technology, “The US Playbook to Address Social Determinants of Health,” The White House, November 2023, https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf; HHS, “Call to Action.”

[15] Taylor and Byhoff; Etsemaye Agonafer et al.; and Nohria et al.

[16] Etsemaye Agonafer et al.

[17] Rachel Hogg-Graham et al.

[18] In a full closed-loop process, “patients complete their referrals, and visit outcomes and plans of care are received by PCPs”: https://www.cms.gov/priorities/innovation/files/x/tcpi-san-pp-loop.pdf. See also Exhibit 1, https://www.chcs.org/resource/adopting-a-community-resource-and-referral-platform-considerations-for-texas-medicaid-stakeholders/.

[19] HHS, “Call to Action.”

[20] HHS, “Call to Action.” 

[21] HHS, “Call to Action”; Domestic Policy Council, “US Playbook.”

[22] Center for Health Care Strategies, “Using Medicaid Levers to Support Health Care Partnerships with Community-Based Organizations,” fact sheet, October 2017, https://www.chcs.org/resource/using-medicaid-levers-support-health-care-partnerships-community-based-organizations/.

[23] Domestic Policy Council, “US Playbook.”

[24] “Introducing the Gravity Project,” Gravity Project, accessed April 30, 2024, https://thegravityproject.net.

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