What Drives us

Since forming in early 2022, the Partnership to Align Social Care has established a collaborative, a co-design structure, stakeholder groups, and workgroups to develop and disseminate resources for multi-sector stakeholders to move alignment between the health and social care ecosystems.

Partnership leaders gathered to discuss community care hubs

Partnership leaders representing cross-sector stakeholder perspectives gathered in Washington, DC to discuss the importance of Community Care Hubs.

The Case for Cross-Sector Co-Design

The US healthcare system is undergoing a necessary transformation. Recognizing the importance of social conditions (such as housing, food, and transportation) to individual and population health, and the role that social inequality and prejudice play in health disparities, healthcare organizations are increasingly focusing on health-related social needs (HRSNs) as part of the healthcare delivery system.

The coordination and alignment of healthcare and social care requires the development of new delivery systems, structures, and capacities that respect the expertise and value of each sector while enabling them to collaborate to jointly serve individuals.

These evolving systems, structures, and capacities collectively are health and social care ecosystems (HSCE). The relevant stakeholders in an HSCE are diverse and include health plans, healthcare providers (hospitals, federally qualified health centers, behavioral health, medical groups, etc.), community-based organizations, government agencies, health and social care technology platforms, community residents, and people with lived experience.

The Partnership to Align Social Care (Partnership) recognizes that there are power differentials between the sectors involved in an HSCE. Past efforts to collaborate between the sectors have failed to adequately account for those differences to the detriment and disservice of the individuals served by these systems. This dynamic has threatened health and resulted in disparities, especially for diverse and low-income older adults and people with disabilities who often rely on home and community-based services and supports (HCBS) to live independently and with dignity in their homes and communities.

A Collaborative Multi-Sector Approach Catalyzing Alignment

The Partnership works to bridge the divide between healthcare systems and Community Based Organizations (CBOs) through active coordination and collaboration on common issues and resources. Achieving this necessitates intentional co-development of structures that acknowledge and overcome power and resource differentials and historical distrust. The goal is that sectors develop shared structures that enable collaboration and coordination to equitably distribute care while retaining their respective strengths and inherent value across populations and settings.

Social services providers have also recognized the importance of working with health care entities to align services and funding in a more effective and equitable manner. Concurrently, health care payers and providers are increasingly recognizing the value-proposition coordinating with community partners to address HRSNs for their patient populations.

A Network and Hub Approach to Reforming Social Care Delivery

Health care and social care providers have long faced challenges stymieing alignment. To address these challenges, a growing number of CBOs are entering contracts with healthcare organizations as part of a network of CBOs performing as a social care delivery system.

This evolution of multiple CBOs operating as a coordinated regional network reflects an administrative approach aimed at achieving maximum operational efficiency and effectiveness, as well as the opportunity to leverage economies of scale inherent in an organized network delivery model. Additionally, an organized CBO network model can ‘level the playing field’ by creating a shared infrastructure that permits smaller CBOs, which lack organizational capacity and resources, to work directly with healthcare organizations by participating in contracting opportunities.

When CBOs organize into a social care delivery system, with the purpose of implementing sustainable, equitable, and scalable interventions, the organization that assumes the lead role within that network–or backbone organization–is the Community Care Hub (CCH).

CCHs provide infrastructure for CBO members of the network to participate in contracts with healthcare organizations. They also serve as a single point of accountability for healthcare organizations that want to contract with trusted CBOs capable of addressing a spectrum of HRSNs. This network of CBOs, known as a community care network (CCN), led by a CCH, can offer the size, regional coverage, range of services, requisite data management capacity, healthcare contracting capability, and billing capacity that allow for many CBOs to operate as an organized regional social care delivery system to improve health outcomes.

Because CCHs increase shared infrastructure, efficiency, and effectiveness of individual CBOs to address HRSNs, they can also reduce costs and improve quality measures for health plans and other payers. By improving access to the right services at the right time, together they work to reduce emergency department visits, hospital admissions and readmissions—they improve clinical outcomes by targeting programs to address social drivers of health.

Foundational Role of the Partnership in Advancing Cross-Sector Backing for CCHs

To date, the Partnership to Align Social Care has provided a unique and promising platform for a comprehensive cross-sector co-design. Each of the organizations that are stakeholders of the Partnership have committed time and resources to define best practices through the co-design of aligned social care delivery models to enable successful care delivery partnerships between healthcare organizations, CCHs, and CCNs.

Partnership stakeholders dialogue, collaborating to create and co-design new tactics, tools, and language to establish and strengthen CCHs. This focus includes how to best facilitate contracting, information on data and coding, and management and governance structures. The Partnership helps to increase effective identification of SDOH needs to connect to these new service systems.

This work synergizes with federal efforts to promote partnerships between health care entities and CCHs. In late 2023, The U.S. Department of Health and Human Services (HHS) released a Call to Action: Addressing Health-Related Social Needs in Communities Across the Nation and additional resources to highlight community care hubs as a vital model for community care coordinated delivery systems.

The Partnership will continue to work with multi-sector partners to advance resources and initiatives that improve alignment between health care and social care sectors. Learn more about Partnership to Align Social Care stakeholders and opportunities to get involved at https://www.partnership2asc.org/stakeholders/.