Frequently Asked Questions

For more answers about the Community-Driven, Multi-Payer Health Equity Solutions: An ECHO Collaborative, read on. Please direct any additional questions about the learning collaborative to

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Frequently Asked Questions

Can I get the materials from the informational session about this opportunity?

Yes! The recording and slides from the session are available to review. Please reach out to with additional questions.

What is a Community-Clinical Team?

A Community-Clinical Team is the applicant group representing multiple stakeholders in a local market with each stakeholder committing to work towards a set of mutually agreed health equity goals. Each Community-Clinical Team will implement targeted interventions to address identified needs impacting the priority population. The members of a Community-Clinical team include the following:

  • Health Plan (Can be “TBD” at the time of application)
  • Health System (Can be “TBD” at the time of application)
  • Medical Providers (i.e., Group Medical Practices, Solo-Practitioners, FQHCs/RHCs, etc.)
  • Community Care Hub/Community-Based Organization
  • Person(s) with Lived Experience representing the community (Can be “TBD” at the time of application)

What if our Community-Clinical Team does not have a committed health plan, health system, or Person with Lived Experience at the time of application, but we agree to engage one or more of each partner during the course of participation?

The learning collaborative will accept applications that do not have a participating health plan, health system, and/or Person with Lived Experience at the time of application. If these partners are not identified at the time of application, submit TBD (“To Be Determined”) in the section requesting the name and contact information partner(s).

Can the Health System and Medical Provider be part of the same larger Integrated Healthcare System where the medical practice is owned by the Health System?

Yes, an Integrated Health System can participate and serve in both roles as the Health System and Medical Provider.

What is a community care hub?

A community-focused entity that organizes and supports a network of community-based organizations providing services to address health-related social needs. A community care hub centralizes administrative functions and operational infrastructure, including but not limited to, contracting with health care organizations, payment operations, management of referrals, service delivery fidelity and compliance, technology, information security, data collection, and reporting. A community care hub has trusted relationships with and understands the capacities of local community-based and healthcare organizations and fosters cross-sector collaborations that practice community governance with authentic local voices. More information about CCHs is available at

Why is the Calendar Year (CY) 2024 Medicare Physician Fee Schedule important for this learning collaborative? And where can I learn more about it?

In July 2023, the Centers for Medicare & Medicaid Services (CMS) announced the annual proposed rule detailing anticipated payment adjustments under the Physician Fee Schedule and other Medicare Part B policy updates for CY 2024. Through this proposed rule, CMS is proposing coding and payment changes for services to address health-related social needs (HRSNs) through separate payments for Community Health Integration (CHI), SDOH Risk Assessment, and Principal Illness Navigation (PIN) services. The proposed codes for CHI and PIN services are the first that are specifically designed to describe services involving community health workers, care navigators, and peer support specialists, and that allow these services to be provided by personnel employed by community-based organizations (CBOs) under the general supervision of the billing practitioner.

To find out more about the CY 2024 Medicare Physician Fee Schedule Proposed Rule, see this CMS fact sheet. Additionally, you may register for the Partnership to Align Social Care webinar hosted on August 22nd to watch the recording titled “What Does the CY 2024 Medicare Physician Fee Schedule Proposed Rule Mean for Addressing HSRN?” and read the Partnership’s comment letter here.

Does the learning collaborative require each community-clinical team to implement Community Health Integration (CHI) Services?

Yes, each community-clinical team will be required to implement the Community-Health Integration (CHI) HCPCS codes as part of a broader strategy to address health equity in their local market. A key component of the learning collaborative is focused on implementing actionable interventions to address the needs of the priority population. The intervention must include addressing Health-Related Social Needs (HRSNs) impacting the priority population. The deployment of interventions to address HRSNs in the priority population will be sustained by each community-clinical team implementing the Community Health Integration (CHI) services and then working to achieve multi-payer alignment with a single model of care to address the needs of the priority population.

The learning collaborative will be an action-oriented process with each team actively implementing and evaluating interventions to drive health equity and improved clinical outcomes in their defined market.

What are the expectations of the Learning Collaborative participants?

  • Actively engage in Learning Collaborative technical assistance activities and provide regular progress updates.

  • Participate in TeamSTEPPS activities as part of a community-clinical team.

  • Identify two or Health Equity goals that the community-clinical team will work to resolve.

  • Develop a CHI Implementation Action Plan to address HRSNs in the impacted priority population.

What is TeamSTEPPS?

TeamSTEPPS is an AHRQ evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare teams, including patients and family caregivers. More information about TeamSTEPPS can be found on the TeamSTEPPS website.

What time commitment should Learning Collaborative participants expect?

Participants should expect an approximate time commitment of 4-8 hours monthly. In addition, each community-clinical team will be required to work on implementation steps for solutions to address Health Equity in their local market outside of the learning collaborative sessions. However, time commitments are likely to vary from month to month.

How long will the Community-Driven, Multi-Payer Health Equity Solutions Learning Collaborative (Health Equity Learning Collaborative) run?

The Health Equity Learning Collaborative (HELC) is anticipated to run from December 2023 through July 2025.

Is this a funded initiative?

Direct funding will not be provided through this initiative; rather, the Learning Collaborative will deliver targeted technical assistance through a variety of different means.

Each community-clinical team will be required to implement sustainable solutions to address the needs of the priority population to include deployment of community health integration (CHI) services that will be billed to application insurance and incorporated into a Multi-Payer Alignment strategy.

Participants may be eligible for future funding opportunities such as the subawards from the Center of Excellence to Align Health and Social Care anticipated to be administered in early 2024.

Participants will have the opportunity to request 1:1 technical assistance with subject matter experts (SMEs), with the SME consulting fee covered through the Learning Collaborative.

What is the difference between the Health Equity Learning Collaboration and the CCH National Learning Community (NLC)?

The NLC is a technical assistance opportunity open to current CCHs and community-based organizations interested in serving as CCHs who have existing contracting capacity. The NLC will provide technical assistance and peer learning opportunities with the goal of building the strength and preparedness of the CCH to address health-related social needs through contracts with health care entities. Proposed billing codes in the Physician Fee Schedule for Community Health Integration and Principal Illness Navigation services will anchor the various ECHO modules.

The HELC is a technical assistance opportunity open to community-clinical teams and is dedicated to implementing and documenting community-driven models of care that promote health equity goal achievement using multi-payer alignment to promote the implementation of Community Health Integration (CHI) HCPCS codes. The clinical-community team, a key feature of the HELC, must consist of at least one representative from each of the following groups: 1) health plan; 2) health system; 3) medical provider (i.e., group medical practices, solo-practitioners, FQHCs/RHCs, etc.), 4) CCH/community-based organization; and 5) person with lived experience. Each community-clinical team will be actively working to develop and report a local implementation model for operating a HRSN screening and invention model that operates under the new community health integration (CHI) and principal illness navigation (PIN) HCPCS codes. The community clinical teams will develop a operational model to actively deploy services to priority populations in their respective markers. The community-clinical teams will operate this model with the expectation that they will seek multi-payer alignment to a single model of care to address HRSNs that incorporates social care services into the model for all payers and use value-based contracting or alternative payment models to drive health equity. For more information on the HELC, please contact Timothy P. McNeill, RN, MPH at

Can organizations take part in multiple technical assistance opportunities offered under the Learning System to Align Health and Social Care?

As indicated above, the NLC is anticipated to run from November 2023 to August 2024. The HELC will run from December 2023 – July 2025. NLC participants will join the HELC learning sessions in December 2023- March 2024, however organizations are encouraged to participate in either the NLC or the HELC in order to dedicate sufficient time and resources to the respective TA opportunities. Recordings and resources developed as part of each technical assistance opportunity will be shared and made available under the Learning System to Align Health and Social Care.

Who do I contact if I have additional questions about the Learning Collaborative or the application process?

All questions can be sent to