12 takeaways from the WHI’s community care hub panel

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The Washtenaw County community has identified access to services, both to health care and to resources that address the social drivers of health, as a critical issue. For those with significant, ongoing health and social needs, access to coordinated, complex services is particularly challenging. 

In 2025, the WHI will prioritize advancing community level strategies to effectively promote integration of social service and clinical care providers to improve the health of our community. 

In launching these efforts, panelists from three Community Care Hubs in New York, Maine, and Kansas City, also known as community integrated care networks, joined the WHI’s December 10 stakeholders meeting to share lessons they’ve learned in their work. The panelists included:

Some of their recommendations were tailored to aspiring hubs, some to community-based organizations that would serve as key network members, and some to the health care entities and other funders who would support them. 

Here are 12 takeaways from the panel discussion, which was attended by nearly seven dozen representatives from the region’s health, behavioral health, social service, insurance, and funding organizations:

  1. Build a robust network. Community care hub networks can include payers, providers, funders, and community-based organizations. Hospitals and health systems, Area Agencies on Aging, local and regional public health departments, independent living centers, state offices and departments (aging, disease control, etc.)–all of these voices are needed for a robust network. But community based organizations (CBOs) will make up the majority of network members–the organizations that provide critical health-related social services like meal delivery, housing, transportation, and case management are essential. “Integrating clinical care happening within the walls of medicine with the social care happening on the ground and in the home with community-based organizations is really when the magic happens,” said Kristi Bohling DaMetz of the Mid-America Regional Council (MARC) and Mid-America Community Support Network (CSN). “When health related social needs are addressed folks are better able to follow medical advice and meet clinical health goals.”
  2. Develop and price a range of services. One hub leader discussed the process of bringing community-based organizations together to choose the kinds of services they wanted to offer and the kinds of people they wanted to serve. There’s a broad range of services that are needed to improve the health of vulnerable populations, of course, so there are lots of services to choose from. Panelists discussed chronic disease and pain management, diabetes and fall prevention programs, in-home screenings and assessments, caregiver support programs, meal delivery and nutrition counseling, community health coaching, care transitions and post-discharge services, housing support and home modifications, and transportation to address health-related social needs. All of these services need to be described, packaged, and priced so hubs can converse and negotiate with payers and funders on behalf of their CBOs. 
  3. Lessen the load of CBOs. “We try to take as much as we can off the plates of community-based organizations by centralizing services and reducing administrative burden so CBOs can focus on people in the community,” said Bohling-DaMetz. All of the hub leaders discussed the services they offered to CBOs in particular, including securing funding, negotiating and contracting with health care payers, facilitating legal contracts, providing the technological infrastructure for secure information exchange, managing referrals, developing workflows and policies, ensuring compliance, collecting and analyzing service data, reporting to funders, billing health care entities, distributing funds to CBOs, facilitating learning communities, providing backbone support for quality improvement initiatives, and more. 
  4. Mind the power dynamics. Community care hub leaders spoke a lot about their CBO members, who make all of their work possible. “We have CBOs embedded in every aspect of our organization,” said Nikki Kmicinski of the Western New York Integrated Care Collaborative. “They sit on our board. They sit on all of our committees. When a new network member is onboarded, they tell us which committee they’re going to join. So we’re constantly getting their feedback and it’s informing the work we do with commercial health plans, Medicare Advantage health plans, and Medicaid health plans.” Bohling-DaMetz discussed the uneven power dynamics inherent in the work of integration. “Again and again, we would hear healthcare entities interacting with community-based organizations and the power dynamic was so different. We knew we needed to find a way for CBOs to have a unified voice in this model to make sure our CBOs stayed strong and healthy.” 
  5. Blend and braid funding. Participating community care hubs shared their many and varied funding sources, each of which funded a specific aspect of their work. Funding came from the US Administration for Community Living, the National Council on Aging, 1115 Medicaid waivers, Area Agencies on Aging, state, local, and regional foundation grants, Medicare and Medicaid billing, contracts with payers and providers, and, for more established hubs, revenue from consulting and technical assistance. Hubs particularly emphasized the need to secure funding for infrastructure and network development whenever possible. “Be in it for the long haul,” Kmicinski told funders. “The first health plan that we contracted with provided us with upfront funds that we could pass down to the CBOs to help them build their capacity.” That kind of support, and also flexible support, is critical, Kmicinski said. “There’s a lot of infrastructure funding that’s needed, especially on the IT side. Healthcare providers all received 90/10 grants to get their EMRs interconnected. None of the CBOs had that so the hubs are trying to do that on behalf of the CBOs to get us connected with the providers to make all those referrals easy and functional.”
  6. Be the bridge. Network members are a diverse group, emphasized Bohling-DaMetz, who said hubs need to act as a bridge between healthcare partners that are very diverse, with different sizes and structures and data and communication pathways, and CBOs that also range in size, services offered, and populations served. “I hear from healthcare entities that they’re hesitant to contract because of capacity challenges in the community. I hear from CBOs that contracts come and go, funding is variable, and that they have to staff up and lay off, making resourcing difficult to predict.” If the hub/network doesn’t acknowledge the connection between sustainable funding and reliable CBO capacity, said Bohling-DaMetz, the model can remain stressed. 
  7. Track outcomes. By tracking outcomes, hubs are able to show health plans–both current and prospective partners–how CBOs can help their members and improve their lives, said Kmicinski. Data collected by the hub showed a 46 percent reduction in fall risks for participants in the falls prevention program, 46,094 post-discharge meals delivered, and high percentages of participants who increased vegetable intake (86%), increased physician or social activity (76%), and reported that receiving meals helped prevent a hospital readmission (73%). 
  8. Set realistic expectations. Together, we need to establish measures of success, figure out where the data will come from, and how to track improvement. In that process, said Bohling-DaMetz, you’ve got to make sure that you have people at the table who are thinking about what truly shows improvement in data. “If we’re thinking about the aging population, for example, improvement can’t be ‘were they less expensive this year than they were last year?’ We have to look at the trend of what their cost would be without this support, and did we, collectively, bend the cost curve?” 
  9. Fund quality improvement. Bohling-DaMetz also talked about the need to fund quality improvement initiatives. “There’s always an opportunity for us to take those learnings and to do better. That’s not typically a consideration with ‘by referral’ transactional funding. Fortunately the USAging Center of Excellence grant is providing investment in infrastructure, standardization, and quality improvement. This is so timely and key to the health of an integrated community care hub.”
  10. Be in it for the long haul. “Think about the big picture, not the flavor of the day,” said Bohling-DaMetz. “I know within plans that’s difficult to do because priorities shift every year. But if we think about the infrastructure that’s needed for social support services–80% of what impacts health outcomes–and the trusted relationships within neighborhoods and communities; nonprofits and CBOs we rely on are at risk of shriveling up and dying on the vine if we don’t invest in a meaningful way rather than a transactional, episodic way.” Bohling-DaMetz, who worked within several CMS Innovation Center model tests, said a lot of feedback from early evaluations noted, “Three years isn’t enough time to see the full impact. So think about what the timeline looks like to truly test this model in your communities and with your members.” 
  11. Be flexible. CBOs have to be ready to change too, said Gerard Queally of the Healthy Living for ME hub. “We’re at the mercy of plans. And the plans are never promising to be there next year. And they all want something a little bit different. Home delivered meals can be home delivered ingredients–medically tailored recipes–just as easily. CBO’s can’t just say ‘we don’t do that.’ They can do that. They need to be willing to do it differently to work effectively with health care entities.” 
  12. Don’t walk away. “Healthcare entities have this perception that the CBOs are already paid to do this work and that the health care system should just be able to make a referral,” said Queally. Referring to an amputee discharged from a hospital with food insecurity, the provider thought they could just refer him to Meals on Wheels. “I couldn’t believe it,” said Queally. “You have to do an assessment. You have to do this. You have to do that. It can take a week or two, there could be a wait list.” If health plans want meals at discharge, they’ve got to pay for it, he continued. “That seems to stun them–stuns health plans and stuns health systems. And the sad thing is, in my experience, is the minute they need to feel like they have to pay for it, they just walk away.”

Tane Lewis, from the Mid-Atlantic Regional Council hub, said that often healthcare entities are trying to get services for people that don’t fit into the restricted categories set by funders. “They either don’t have a specific diagnosis that qualifies them for that chronic care or they don’t meet the age requirements or the homebound requirements,” said Tane. “Getting healthcare entities and our partners to understand that the funding that we have in existence is not going to cover their patients can be hard.”

“You’ve almost got to believe that a community care hub is needed in order to have the patience to stick with it,” said Queally. The other panelists concurred. 

The presenters made a persuasive case for the value of community care networks and hubs in reaching more individuals with more coordinated, targeted services than the current mix of stand-alone health and social service organizations. Networks and hubs may be a better way to ensure patient recovery in a world where social needs have an outsized impact on health while also ensuring payers and providers earn enough revenue to thrive as our healthcare system continues to move toward a value-based payment structure. 

The WHI will look to continue these conversations locally, with planning already underway to host a “State of the State” summit March 18, 2025 that will give local stakeholders an overview of state and local initiatives already underway that could support the better integration of health and human services.

If you did not attend but would like to receive updates on this work, please reach out to Matt Hill at hillmat@med.umich.edu.