ACL Business Acumen Summary Report |September 18, 2020|p. 1

The National Summit on Health Care and 

Social Service Integration: Foundational 

Efforts and Rationale for Integrating Health 

Care and Social Services

Introduction

Health care providers, payers, and systems are increasingly interested in approaches that 

address both medical needs and social determinants of health (SDOH). The need to reduce 

health care utilization while improving quality of life, as well as promoting the self-management 

of chronic health conditions is more important than ever as the health care sector transitions to 

value-based payment models. Integration of care allows for the provision of services delivered 

in the home and in the community that prevent falls, address food insecurity and 

transportation issues, manage chronic disease, support employment and economic 

independence, reduce social isolation, and address other non-clinical risk factors. These 

essential services are shown to improve health outcomes and reduce the cost of care. This is 

particularly true for “high-need, high-cost” people who have complex health conditions and 

social risk factors and who often have significant functional limitations. Moreover, care 

planning for such individuals can become heavily medicalized, at the expense of more 

individualized, person-centered planning.

Integrating these services into health care delivery requires robust planning and assessment, 

expert knowledge of how to navigate complicated social service systems, ongoing case 

management, and accountability for service delivery and outcomes. It also requires health care 

payers and providers either to “build” internal organizational capacity or to “buy” additional 

capacity from existing service providers. When making that decision, there are many factors for 

health care organizations to take into consideration, not the least of which are local factors in 

the communities and markets they serve. In other words, integrating SDOH into traditional 

health care is a sizeable undertaking. For many organizations, partnering with existing networks 

of community-based organizations is a more cost-effective strategy for providing quality 

services and supports.

To succeed, plans for integration must draw on the expertise of stakeholders across the nation. 

These stakeholders include community-based organizations (CBOs) and their networks; state 

agencies (e.g. aging, mental health, intellectual/developmental disabilities); national 

associations; federal agencies, especially those within the U.S. Department of Health and 
ACL Business Acumen Summary Report |September 18, 2020|p. 2

Human Services (HHS); health plans and health systems; and experts in SDOH financing and

health information technology (IT).

Starting in the fall of 2019, the Administration for Community Living (ACL), an operating division 

of HHS, undertook a series of activities to engage these stakeholders in conversations on how 

to grow and strengthen the network of CBOs that provide integrated health services addressing 

both medical needs and SDOH. As of the spring of 2020, those activities include:

1. Interviews with key informants in October and November of 2019.

2. A small roundtable of approximately 25 CBO stakeholders convened in Washington, DC, 

on December 5, 2019.

3. Semi-monthly conference calls and presentations with a workgroup comprised of select 

participants in the December roundtable.

4. A national Summit convened in Washington, DC on March 4, 2020, attended by more 

than 150 participants representing organizations ranging across federal and state staff, 

thought leaders, CBO network experts, health plan and health system decision-makers, 

and national associations and foundations representing these organizations and the 

aging and disability community.

This report begins by reviewing these activities and then synthesizing their outcomes into a 

model for how CBOs and their network partners can transform themselves into communityintegrated health networks (CIHNs) by addressing issues of financing, data and technology, 

governance, and scaling up from the local, state, and regional levels to a national-level CIHN. 

Understanding the Challenges Associated with Integrated Health and Social 

Services

Key Informant Interviews

ACL recognizes the value of the aging and disability network, particularly community-based

organizations (CBOs), as integral to the integration of health and social care. When networks of 

CBOs act in partnership with providers, payers, and health systems, the resulting integrated 

system can lead to better outcomes and lower costs. Networks will be especially effective if 

they emphasize values of trust, shared leadership, accountability, sustainability, and innovation.

In October 2019, ACL conducted interviews with stakeholders with expertise in business 

acumen among CBOs and CBO networks that provide long-term services and supports (LTSS). 

ACL conducted these interviews to gain an understanding of how these individuals in the field 

view the present state of service delivery and their expectations for the future. The interviews 

elicited expert opinion on the business acumen needs and priorities of CBOs and CBO networks; 

the role of state agencies and CBOs serving older adults and individuals with disabilities and 
ACL Business Acumen Summary Report |September 18, 2020|p. 3

their families; and state-level promising practices related to business acumen. Two main 

themes emerged from these discussions: (1) the need to address siloed services, and (2) the 

need to clarify the gaps and strengths of CBOs.

In December 2019, ACL held focus group discussions with state and health plan leaders,

including participants of an SDOH-related learning collaborative convened by America’s Health 

Insurance Plans (AHIP). Participants reached a consensus that establishing a strong network 

lead entity (NLE) – an organization that acts as a single point of accountability for health care 

organizations — could help CBOs standardize practices, execute effective contracts with health 

care organizations, and develop capacity. Additionally, there was agreement that, to move 

toward scaling CBO networks, an established method of electronic data exchange is necessary. 

Finally, the leaders agreed that, while buy-in from state system leaders is important, education, 

culture change, and buy-in across the local level are essential.

Table 1 provides a summary of the stakeholders and a brief biographical sketch. 

Table 1. Interviewees and Focus Group Members

Name Date Description

Tim McNeill, 

Freedmen’s 

Health, LLC, 

Health Care

Consultant

10/18/2019 Mr. McNeill specializes in health program development and 

sustainability. He has worked with many federal level 

clients, including the U.S. Department of Health and 

Human Services (HHS), U.S. Administration on Aging (AoA), 

and ACL, as well as state level leaders, CBO leaders, and 

health system and plan executives in his career.

Kevin Moore, 

Vice President 

of Policy, 

Health, and 

Human 

Services at 

UnitedHealth 

Group

10/30/2019 Prior to joining UnitedHealth Group, Mr. Moore was the 

Senior Vice President of Medicaid Strategy for Aurora 

Health Care and the Medicaid Director for Wisconsin’s 

Department of Health Services. He has over 16 years of 

experience in LTSS, managed care, Medicaid, public health, 

and clinical health care for individuals with disabilities. Mr. 

Moore specializes in the development of sustainable 

interventions that improve community health by 

identifying and addressing social, economic, workforce, 

transportation, and nutritional barriers.
ACL Business Acumen Summary Report |September 18, 2020|p. 4

Name Date Description

Jacob Reider, 

CEO of 

Alliance for 

Better Health

10/23/2019 Dr. Reider is a family physician with more than 30 years of 

experience in health policy and health IT, with a special 

interest in user experience, clinical decision support, and 

information portability. He currently serves as CEO of 

Alliance for Better Health, a New York Delivery System 

Reform Incentive Payment (DSRIP) program care 

transformation initiative, and as adviser and board 

member for several private sector organizations focused 

on health and health care.

Focus Group 

with State 

Leaders, 

ADvancing 

States 

leadership

12/10/2019 This focus group convened state leaders and 

representatives from ADvancing States to discuss the role 

that state leaders have in addressing SDOH and fostering 

networks of CBOs. Participating state leaders came from 

Alabama, Alaska, Florida, New York, and Virginia.

Focus Group 

with America’s 

Health 

Insurance 

Plans (AHIP) 

Project Link 

Learning 

Collaborative

12/11/2019 This focus group call provided ACL the opportunity to listen 

to participants in AHIP’s Project Link Learning Collaborative

on partnering with CBOs to provide services to address the 

needs of older adults and individuals with disabilities.

Participating health plans included Kaiser Permanente, 

UCare, SCAN Health Plan, Highmark Health, Fallon Health, 

and AmeriHealth.

The information gleaned from each of these discussions helped identify promising practices, as 

well as the opportunities and challenges inherent in CBO partnership with health plans and 

systems. 

· Mr. McNeill discussed the importance of a single point of accountability, or NLE, while 

scaling CBO networks, and the role of supplemental benefits in terms of market 

competition.

· Mr. Moore helped conceptualize an efficient and high performing value-based payment 

model. He supported ACL’s prioritization of SDOH, avoiding siloed systems and the 

medicalization of CBOs, and the role of Medicaid expansion policies.

· Dr. Reider provided insights into how health care providers view the challenges and 

opportunities for integrated care partnerships.

· The ADvancing States focus group shared promising practices on how to move toward a 

person-centered, value-based payment model. They emphasized the role of education, 

culture-change, and buy-in of stakeholders across all levels.

· AHIP Focus Group discussed the benefit of having formalized partnerships between 

CBOs and health care plans as well as the role of established electronic data exchange.
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The discussions both informed ACL’s thinking and led to the formation of the deliverables 

outlined in this paper, as well as the development of the CBO Roundtable and Summit agendas.

Enhancing Community-Based Networks for Nationwide Capacity Roundtable 

The Enhancing Community-Based Networks for Nationwide Capacity Roundtable was hosted in 

Washington, DC, on December 5, 2019. Attendees came from the aging and independent living 

community, as well as national organizations, institutes, and associations interested in the 

integration of care more broadly, including:

· Representatives of the aging and independent living communities.

· Senior leadership at Area Agencies on Aging (AAA) and Aging and Disability Resource 

Centers (ADRCs).

· Senior leadership at national organizations specializing in quality.

· Senior leadership at institutes that support business development among CBO networks.

· Senior leadership at foundations that specialize in grant making to support innovative 

community LTSS programs.

· Senior leadership at foundations, nonprofits, and institutes that support the spread of 

services that address SDOH by promoting research, promulgating best practices, and 

awarding grants.

· Consultants specializing in service financing, health IT, and interoperability.

A full list of attendees is found in Appendix A.

Roundtable participants learned of ACL’s core aims to develop business acumen among CBO 

networks and proposed efforts to help CBOs scale from the local level to the state, regional, or

national levels. Participants also learned of and provided feedback on ACL’s suggestions for 

what networks might look like and how they might partner with health plans and health 

systems. ACL’s suggestions were supported by presentations of CBO network developers and 

contractors who have supported similar efforts. 

The group discussed the following topics:

· How health plans and systems might invest in CBO network development, and 

whether they should be considered formal members of those networks or as 

purchasers of the services that those networks offer.

· The key role that the direct care workforce plays in ensuring that the demand for 

services can be met.

· The importance of recognizing that some CBOs are more ready than others to assume 

the role of a network lead entity.

· How to promote collaboration among neighboring lead entities.
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· How emerging networks might deepen their expertise in health IT and data analytics 

by joining with partners that already have the necessary expertise.

· Ways to minimize the administrative burdens that a hub-and-spoke model might 

create.

· Strategies for partnering with Medicaid managed care organizations (MCOs) and 

Medicare Advantage as key purchasers of network services, especially by using payfor-performance financing models that can make purchasing services more attractive 

to potential buyers.

· The importance of adopting evidence-based practices that are also person-centered.

Following the group discussion, participants divided into break out groups to discuss two topics: 

(1) payment and financing and (2) technology. Breakouts were facilitated by identified leaders 

in the field – Tim McNeill for payment and financing and Dr. Reider for technology. Table 2

provides more information on the main discussion points of these breakout sessions.

Table 2. Roundtable Breakout Groups

Breakout 

Session

Main Discussion Points

Finance · The need to support CBOs (and health plans and payers) to determine 

how to price network services

· The need to support CBOs in demonstrating strong return on 

investment (ROI) to purchasers

· The need to educate prospective purchasers, especially hospitals, 

about the impact of SDOH on outcomes (for example, by reducing 

rates of re-hospitalization, for which hospitals are typically penalized)

· The importance of securing a “place at the table” early in discussions 

between states and MCOs, well before a state opts to issues a request 

for proposals (RFP) for MCOs, when it is still possible to make the case 

that MCOs should be required to purchase such services
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Breakout 

Session

Main Discussion Points

Technology · The power of technology platforms to promote closed loop solutions, 

from referral to service delivery to outcome assessment

· Fragmentation of health IT systems, including those built by large 

health systems, and those created by vendors that sell to large health 

systems, which often creates an inability to interoperate and thus

propagates “walled gardens” of data

· Challenges in moving any system, or set of interoperable systems, to a 

national scale without a large-scale federal push that comes with 

funding

· The role that HIPAA – and data security and privacy more broadly –

must play in CBO use of health IT platforms. It may be useful to 

develop a privacy and security standardization toolkit geared 

specifically to CBOs.

The day ended with a “call to action” from Roundtable participants to continue the 

conversation – and support ACL in identifying appropriate next steps and structures required to 

scale integrated networks nationally. 

Roundtable Workgroup

A subset of Roundtable participants, listed in Appendix A, agreed to meet twice a month to 

discuss key issues that arose during the Roundtable. The composition of the Roundtable 

Workgroup broadly resembled the composition of the Roundtable itself. Several members led 

CBOs and CBO networks, two were leaders of a prominent non-profit, and two represented a 

national association.

The Workgroup had four immediate goals:

1. Increase situational awareness of CBO-led network activity and development.

2. Clarify the roles and responsibilities of CBO-led networks.

3. Identify and discuss potential strategies and tactics to reach nationwide coverage.

4. Develop communication protocols for how to describe CBO networks.

Between January and March 2020, the group met regularly five times. Over the course of its 

five meetings and the weeks between, the Workgroup:

· Supplied details about existing networks, including their names, locations, network 

leads, and geographic scope (local, statewide, etc.).

· Discussed the range of challenges in coordinating community LTSS that CBO networks 

might solve.
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· Decided on a name for such networks: community-integrated health networks (CIHNs).

· Decided on a name for the lead organization in such networks: network lead entity 

(NLE).

· Identified the five attributes that comprise the value proposition of a network (detailed 

below).

· Discussed the set of core services that CIHNs should offer or coordinate, including 

assessments, information and referral, medication management, nutritional assistance, 

transportation assistance, and personal care and chore services.

· Provided feedback on several drafts of a paper to be distributed as pre-reading to those 

attending the National Summit on Health Care and Social Service Integration in March.

· Discussed emerging network needs connected to the COVID-19 pandemic. Concerns 

regarding the pandemic were the importance of flexible service delivery, avenues of 

communicating with other CBOs that may be experiencing similar shortages and needs, 

and securing additional funding. Nutrition services, social isolation, and childcare were 

the areas most impacted by COVID-19, with many CBOs experiencing severe shortages 

in the workforce needing to address these issues.

The Workgroup identified the following five attributes as central to the value proposition of a 

CIHN:

1. Trust: Networks leverage existing relationships in the community to ensure that 

individuals feel understood and supported.

2. Leadership: Social service and health care decision-makers share leadership 

responsibilities in planning and managing social assessments, referrals, service delivery, 

and team-based, holistic care.

3. Accountability: Social service leaders implement a system of accountability and quality 

improvement at all levels using agreed-upon performance benchmarks, frameworks for 

regular reporting, and data-driven strategies for improvement.

4. Sustainability: Networks finance services that address SDOH through multi-payer 

arrangements that build community capacity. Over time, they transition from a fee-forservice payment model to value-based/risk-based payment models for delivering social 

services in comprehensive, coordinated care environments.

5. Innovation: To maximize efficient delivery of services and health outcomes, networks 

implement, evaluate, and iterate evidence-based interventions and innovative care 

models.

The paper the Workgroup helped ACL draft in advance of the Summit, included in Appendix B,

consisted of a preamble containing the attributes described above; a review of the evidence 

showing that, by addressing SDOH, CIHNs improve medical outcomes and lower costs; a 
ACL Business Acumen Summary Report |September 18, 2020|p. 9

discussion of how CIHNs could be organized with an NLE; and a review of the common services 

that CIHNs might coordinate or provide.

National Summit on Health Care and Social Service Integration

The National Summit on Health Care and Social Service Integration took place on March 5, 2020

in Washington, DC. More than 150 people attended. Participants were affiliated with federal 

agencies, state agencies, health plans, health systems, national associations, AAAs, Centers for 

Independent Living (CILs), universities, philanthropy, advocacy groups, and more.

The Summit’s main goals were to develop a shared approach for integrating medical and social 

care, highlight integrated models that have demonstrated significant success for older adults 

and people with disabilities, and develop strategies for effective CBO-health care partnerships. 

To achieve these goals, ACL requested support from both federal and private entity partners to 

present and facilitate discussion. The Summit focused on ACL’s vision for better outcomes and 

lower costs through community partnerships, which includes community integrated health 

networks that collectively build nationwide capacity to deliver services through multi-payer 

financing models and shared technology platforms. The Summit also highlighted the current 

state of health care and social services integration. To help align participant interests and next 

steps, ACL elicited feedback from participants on a set of shared goals and principles to frame a 

person-centered approach to integrate health care and social services. The attendees 

envisioned the structure of CBOs to move toward a tiered model founded in shared leadership 

responsibility between social service and health care decision makers. Attendees agreed that 

CBO networks could be built at local, regional, and statewide levels, and establishing strong 

NLEs would ensure quality, standardization, and enforcement of adequate contracting across 

the CBO networks.

The day continued with discussing key opportunities for States and ended in a series of 

breakout sessions to allow for both networking and further discussion on the topics of financing 

social care; scaling networks of CBOs; technology enablers and barriers; and the role of federal 

and state governments. 

Each session of the Summit allowed both presenters and participants to identify opportunities 

and actions to take to support this national effort. Highlights from each session are outlined in 

Appendix C.

Developing Community Integrated Health Networks

Throughout all efforts, ACL explored the current system and identified gaps and barriers to 

achieving an integrated health and social service system. These activities allowed ACL and all 

stakeholders to draw upon shared expertise. Through this engagement with stakeholders, ACL 

determined ways that CBOs and their network partners can transform into CIHNs by addressing 
ACL Business Acumen Summary Report |September 18, 2020|p. 10

issues of financing, data and technology, governance, and scaling up from the local, state, and 

regional levels to a national level of CIHNs. Shared understanding of the value of CIHNs is 

paramount to this work.

Value of Community Integrated Health Networks

CIHNs are coordinated groups 

of visible and trusted CBOs 

that have entered into a 

formal partnership with 

health care organizations with 

the goal of integrating health 

care and social services. 

Integrating social services with health care is critical to 

effectively addressing SDOH. Anecdotal evidence from 

existing CBO and health plan and/or system partnerships 

reflect the value of network development. CBOs that 

form networks in the community can more easily contract 

with larger health plans and health systems to bring social 

service delivery systems into the health care marketplace. 

As organizations established in the community that 

clients already trust, CBOs can facilitate the various 

health and social care services available to individuals as they live in their communities among 

family and friends or, following admission to a nursing home, they transition back to their 

communities These transition services will, in turn, streamline the care an individual receives, 

leading to lower overall costs and a decreased likelihood of readmission to the hospital. Figure 

1 shows how CIHNs can integrate care across the myriad LTSS that individuals need to navigate 

to address SDOH.

Figure 1. Value of a Community Network
ACL Business Acumen Summary Report |September 18, 2020|p. 11

These networks, known as CIHNs, reflect collaboration between health care organization and 

social service networks and are associated with higher performance and reduced health care 

costs.CIHNs are led by a NLE, an organization that assumes responsibility for directing the 

development and design of a network structure, facilitates services, and provides 

administrative oversight and governance. A significant advantage of NLE-led CIHNs is their 

capacity to provide services at different geographic levels to meet the market demand of health 

plans’ and systems’ geographic footprint, such as (1) community-wide; (2) statewide; (3) 

regionally across state lines; and (4) nationally across multiple states. Figure 2 shows how an 

NLE can coordinate CBOs within the CIHN to work with health systems and health plans to 

integrate social services for patients. 
ACL Business Acumen Summary Report |September 18, 2020|p. 12

Figure 2. Potential CIHN Structure

While the development of CIHNs requires robust planning, coordinated efforts to align services, 

and strong commitment from participating entities, the benefits of these networks and the 

formal partnerships with health care organizations are numerous. Studies indicate that the 

integration of social services and health care can lead to lower costs, lower hospitalization 

rates, and improved outcomes for patients.

Alongside financial and value-based metrics, such as those outlined in the case study on 

VAAACares® , CIHNs improve health and social system by offering the following:
ACL Business Acumen Summary Report |September 18, 2020|p. 13

· A broader array of social services through partnerships.

· The potential to reach a greater number of the population in need through a broader 

geographic reach into the community.

· The opportunity to serve as a one-stop coordinated system to link consumers to 

whichever services they may need.

· The development of a stronger administrative infrastructure for delivering SDOH

services.

· The potential to offer positive impact at economies of scale.

· The chance to improve overall care management for individuals.

· The chance to capitalize on a unique position to partner with health systems and health 

plans to establish and promote deeper collaborative efforts.1

CIHNs Successes: 1

VAAACares,® a statewide one-stop coalition providing care coordination, care transitions, 

and other services, reduced the 30-day readmission rate from 18.2% to 8.9% through 

their partnership with four health systems, 69 skilled nursing facilities, and 3 health 

plans.

Elder Services of the Merrimack Valley, a AAA in northeast Massachusetts, and their 

network of community partners have shown an 11% reduction in total cost of care 

through their collaboration with health care organizations.

The Veterans Health Administration, through the Veteran Directed Care program, has 

had purchasing agreements over the last decade with CBO network organizations across 

37 states to provide nursing-home-eligible veterans with a counselor and a monthly 

budget to obtain the long-term services and supports they need to live in the 

community—at about one-third of the cost of a nursing home.

Strong, established CIHNs have unique positions in their diverse communities. With strategic

partnerships with health plans and systems, CIHNs bring integrated care to the individuals in 

their communities. 

Key Challenges for CIHNs

The work that ACL undertakes is designed to further understand and address key challenges 

and opportunities that CIHNs currently face as they gradually develop broader partnerships. 

Four key domains for integrating health and social care require focused attention and 

collaboration:

1. Financing Social Care
ACL Business Acumen Summary Report |September 18, 2020|p. 14

2. Data and Technology Interoperability

3. Governance and State Leadership

4. Scaling 

The sections that follow will discuss each of these domains in turn.

Financing Social Care

As organizations think about how to finance social care, it is crucial to understand how to 

establish a shared payment model to support the integration of social and medical care. There 

are various ways to do this, but a multi-payer system is likely the most feasible model for 

funding social service delivery effectively to ensure the sustainability of the networks. A multipayer system engages multiple payer sources to support the collective business goal of 

integrating the social and medical care services into one network. Multi-payer systems work 

together to identify and define how to best support the payment of comprehensive social 

service and medical costs by blending services and payments. Other multi-payer systems 

engage different payers for scaled services across multiple payers to support the provision of 

services to individuals in need within the community.

Challenges with financing social care services consistently arise when it comes to billing. 

Stakeholders engaged in the aforementioned interviews noted that there is frequently a 

mismatch in the language used to describe services, and that mismatch impacts how 

organizations perceive billing to Medicaid. There is an opportunity to better align language in 

contract development and writing with the perspectives of CIHNs and the ideal multi-payer 

system partners. Unfortunately, CBOs are often not at the table when initial discussions of 

Medicaid or Medicare contracts occur, when there would be an opportunity to align billing 

codes for social services across systems. At the state level, when waivers and waiver programs 

are being developed or operationalized, agreements with health plans are implemented two to 

three years before a Request for Proposals is released. This usually leaves CBOs out of the loop 

and misses an opportunity to ensure CBOs can provide the essential input and prepare waiver 

processes from the start of implementation.

CBOs must understand the value of attending public events and providing public comments to 

share their perspectives on how alignment between systems can promote further integration 

between social and health care services. National associations and organizations, such as n4a, 

can provide educational opportunities to CBOs and encourage them to take a seat at the table 

when initial conversations are held. Including CBOs in contract discussions can lead to contract 

language that is clear and concise and that enhances the integration of health and social 

services to the benefit of people in need. Stakeholders and leaders should encourage CBOs to 

contribute to the national transition to an integrated system. The integration of traditionally 
ACL Business Acumen Summary Report |September 18, 2020|p. 15

siloed organizations can strengthen relationships with legislators and with providers at every 

level of the system. 

For instance, partnerships between CIHNs and Medicare Advantage plans can promote service 

innovation. CIHNs can identify individuals with specific health conditions or social risk factors 

and address needs left unmet by medical providers. Additionally, CIHNs can persuade 

additional payer-partners to work with them. If CIHNs participate in early Medicare Advantage 

conversations held among the state, health systems, and health plans, they could learn how to 

design programs and services that allow CIHNs to strengthen the whole service delivery. This 

would promote service integration in the initial stages of program development and thus 

require less effort to make revisions or clarifications later. 

Data and Technology Interoperability

Self-sustaining CIHNs depend on data 

technology to support the successful 

integration of social services and health 

care. If data are not shared, services will 

not be delivered efficiently and effectively 

to those who need it. Poor service 

coordination can leave individuals in need 

at increased risk of poor health outcomes. 

A lack of system interoperability and data

sharing represent the largest 

technological barrier to integrating social 

services and health care. The problems 

that follow are exacerbated by:

· Difficulties navigating and aligning legal requirements, state-specific regulations, and 

data sharing policies and procedures across partners.

· Data infrastructure capabilities.

· Inconsistent definitions of data elements and technical specifications.

· Frequent updates to technological platforms.

· Lack of sufficient training.

· Competitor dynamics.

· The need to change existing processes to allow for data sharing. 

Furthermore, less robust technological systems can lead to billing issues, as well as impede 

quality measurement, performance monitoring, and real-time refinements of care plans and 

service delivery.

What is interoperability?

According to Health Information Management 

Society System (HIMSS), interoperability is the

ability of different information systems, 

devices, and applications (or “systems”) to 

access, exchange, integrate, and cooperatively 

use data in a coordinated manner, within and 

across organizational, regional, and national 

boundaries, to provide timely and seamless 

portability of information, and optimize the 

health of individuals and populations globally. 
ACL Business Acumen Summary Report |September 18, 2020|p. 16

The success of integrated health and social care solutions depends crucially on interoperability. 

It promotes improvements in information sharing across the entire CIHN and its health 

partners; allows access to accurate, up-to-date information at the right time to support 

informed and person-centered care; and reduces burdens on providers and CBOs trying to 

promote a holistic care delivery system. As efforts to promote CIHNs and partnerships between 

CBOs and health care organizations advance, it will be critical to establish procedures to share 

data and support interoperable systems that work for both health care and social service 

systems. Key elements to consider when establishing the infrastructure for integrated care 

include closed loop referrals, data standards, governance, policy, informed consent, and 

privacy.

Typically, exchanging data between providers and CBOs requires complex systems that can 

communicate between CBOs in the CIHN, as well as partner health systems and health plans. 

CIHNs must have systems capable of receiving electronic information as well as transmitting

information to payers. However, since CIHNs are actively forming and developing broader 

networks, there is an opportunity to streamline and create a data system platform that works 

for both parties from the onset. 

There are many opportunities to build the necessary interoperable infrastructure and ensure 

that all partners can communicate electronically. Technological infrastructure development 

should focus on ensuring coordinated language amongst partners, aligned financial incentives, 

shared interpretations of provider laws, and trust between partners and the individuals they 

serve. Federal agencies, such as Office of the National Coordinator (ONC), working with the 

Centers for Medicare and Medicaid Services’ Center for Medicare and Medicaid Innovation 

(CMS CMMI), can support these efforts by establishing standardized guidance on what data is

collected and what standards to apply. Guidance could focus on existing technical standards 

(e.g., HL7 and IEEE) that minimize technological complexity. State leaders, executives from 

health systems and health plans, and community leaders should support efforts to standardize 

terminology, data structures, and definitions for data platforms. 

Governance and State Leadership

To manage ongoing activities and promote expansion, CIHNs require strong leadership by a 

governing body. A governing body is a partnership between a variety of entities involved in the 

delivery of health and social services. The governing body oversees and organizes the CIHN; 

gathers and incorporates input from stakeholders; and guides the network toward a 

streamlined, person-centered, accessible, and cost-effective technological infrastructure. 

Governance should establish a clear mission to drive the work of all stakeholders.

Robust governance from the beginning can improve chances of success in scaling, financing, 

and data sharing. Stakeholders from all levels, including NLEs, community leaders, state and 
ACL Business Acumen Summary Report |September 18, 2020|p. 17

regional leaders, health system and health plan executives, and federal support, should

participate in governance activities. Federal agencies (including ACL and CMS), state agencies 

(including the State Unit on Aging [SUA] and Medicaid Agency), aging and disability 

organizations, and health plans and health systems all play a role in the development and 

acceleration of integrated health and social care. There is an opportunity for all stakeholders to 

get involved, foster relationships and partnerships, and support the development of strong 

CIHNs. 

Stage agencies – especially SUAs — can convene these meetings and facilitate conversations 

among partners by bringing the broader perspective of the state, while health plans, health 

systems, and CBO leaders understand exactly what services are needed and how they can build 

an effective partnership. As the convener, the state can influence policies that support the 

integration of health care and social services. More specifically, states can foster relationships 

between the state’s Medicaid Agency, CBOs, CIHN leaders, health plans, and health systems

and opportunities from organizations outside of the state. It is important to focus on how the 

state’s work aligns with the work of other agencies and how to champion the network 

throughout the state. 17

For CIHNs to develop and establish successful partnerships with health systems and plans, they 

must identify a workable way to handle governance from the outset. Due to their unique 

position, states play an instrumental role in establishing a governance structure among 

partners. A potential structure of a governing body or governing arrangement appears in Figure 

3. 

Figure 3. Governance Partners

State support can vary and depend on regional and local need for health and social care 

integration. States can support partnership development, identify the model (e.g. regional, 

multi-state, etc.) of integrated care that best meets state goals, align contracts with integrated 

health and social care in mind, and provide management and/or oversight of networks and 

resultant outcomes. Further, states can support CBO activities such as developing business 

operations and refining business acumen skills and capabilities, including expectations for 

integrated care, contractual and financial options, service menu determinations, and 

technology opportunities. States also have the chance to strategically align state Medicaid 
ACL Business Acumen Summary Report |September 18, 2020|p. 18

policies (e.g., managed long-term services and supports) with CBO infrastructure. States can 

formulate guidance for CIHNs, focusing on how they can support credentialing. For example, 

Wisconsin included benefits and coverage for social services in their 1915(c) waiver. 

It is important to determine the right balance of CBO representation within the network, 

participation or representation from health plans and systems, and the specific roles that state 

agencies can assume. This may look different in every state, or even between regions within 

one state, but involvement of the right partners at the leadership level can support successful 

CIHNs. 

Scaling 

Scaling CIHNs, growing the size and reach of these networks to allow for a greater geographical 

footprint within a region, state, or across multiple states, begins with understanding the 

importance of maintaining consistency of services, adhering to access standards, ensuring 

quality of care, and enabling data sharing across CBOs and health system platforms. Data

governance, standards for health information exchange, billing, consent and privacy 

regulations, and closed-loop referrals must be established to achieve interoperability. One of 

the greatest barriers to interoperability is the ability to calculate the ROI to ensure sustainability 

and consistent standards. Networks in different communities, with varying architectures or 

available resources, can approach these goals differently.

CIHNs have moved forward based on what works best for the organizations that are coming 

together in partnership to form the network. For instance, some CBOs have joined existing 

networks, while others have formed CIHNs with other organizations in their own communities. 

One of the biggest considerations for these various approaches is the ability to finance start-up 

costs and manage service delivery at scale. Creating CIHNs or joining existing CIHNs allows CBOs

to begin integrating social services with existing health care systems without having to assume 

all the risk of building a new system. CIHNs are beginning to look to potential collaborators to 

support other areas of scaling up. For instance, to further support their growth, CIHNs can turn 

to other experts to support the development of data or IT infrastructure. Adding some 

collaborators, such as IT vendors, will often come with costs (since CBOs will purchase the 

services of those vendors). However, if these partnerships enable CIHNS to form strong, holistic 

service delivery systems, these costs may yield a higher ROI.

As CIHNs scale and more and more partners come together, consistency will matter greatly. 

Services and processes must be consistent across settings – in the home, in the community, and 

in health systems. Building this consistency into contracts, quality certifications, and data 

sharing can lead to efficiency. For example, Bay Aging, a AAA in the state of Virginia, has 

successfully developed a CIHN that supports partnerships with health plans across the state. 

Their efforts focused on creating consistent services among partner CBOs and consistent 
ACL Business Acumen Summary Report |September 18, 2020|p. 19

processes for coming into the network, subsequently expanding work with local health systems 

based on the established processes that Bay Aging put in place. With this focus on consistency, 

they successfully certified staff members and expanded contracts with MCOs, Veteran Directed 

Care (VDC) providers, and options counselors. All the CBOs that work together in the Bay Aging 

CIHN follow the same successful service guidelines. 

To develop and scale CIHNs, stakeholders must coordinate their strategies for workforce 

development. Providing access to services is only beneficial if the network has the capacity and 

the staffing to deliver those services. CIHNs cannot scale up without a coordinated strategy to 

develop the size and skillset of the direct care workforce. 

Identified Action Items

ACL’s engagement with stakeholders over the last six months has produced several action items 

in the four key domains of integrating health and social care for payers at all levels. These 

action items appear in Table 3.
ACL Business Acumen Summary Report |September 18, 2020|p. 20

Table 3. Identified Action Items

Financing Social Care

§ Develop provider-agnostic care delivery 

system of SDOH sustained through 

reimbursement from multiple payers

§ Outline how to establish CIHNs as bestpractice partnerships that supports the 

integration of funding and services

§ Work with CBOs to market their value

§ Position CBOs as collaborators, not 

competitors

§ Share best practices with key partners

Governance & State Leadership

§ Outline and clarify roles for funding, 

regulation, oversight, and policy 

development through collaborative 

efforts

§ Seek clarification from federal partners to 

identify funding pathways and support in 

clarifying roles

§ Determine how best to maximize revenue 

and funding at the state and local levels

§ Ensure accountability with funds and 

adherence to regulations

§ Support CIHN development and data 

integration efforts

§ Share best practices with key partners

Technology

§ Continuously acquire data, aggregate 

data, analyze data, and act on the 

findings (4As)

§ Build infrastructure to support data 

integration and interoperability by

ensuring consent and sharing data

§ Create a standardized means for referrals 

and ensure closed-loop referrals

§ Catalog best practices and share with key 

partners, including state and federal 

partners

Scaling

§ Expand CIHN development, as well as

data integration and interoperability at all 

levels

§ Establish CBO-network credentialing 

process

§ Establish a common process for 

developing partnerships

§ Establish quality monitoring guidelines

§ Lead or join together to form CIHNs

§ Share best practices with key partners

Conclusion

ACL’s engagement with stakeholders has proven fruitful. ACL gathered vital intelligence from 

key players, including those working on the front lines to help CIHNs mature and knit together

regional networks into a network with nationwide coverage. Several pressing challenges 

remain, however, in the following domains:

1. Determining a network’s value proposition and ROI for prospective partners

2. Shifting financing to value-based payments or similar risk- and outcomes-based models

3. Preparing to partner with health plans and health systems

4. Ensuring interoperability of data systems and databases

5. Clarifying the role of federal and state partners
ACL Business Acumen Summary Report |September 18, 2020|p. 21

It is important to note at the outset that valuable tools already exist to help NLEs and the CIHNs 

they head to meet some of these challenges – most notably, the tools available through the 

Aging and Disability Business Institute and the HCBS Business Acumen Center. It is unclear, 

however, how often networks use these resources. And there are some topics – such as health 

IT interoperability – that are not fully addressed by the tools these centers have made available.

Network Value Propositions and ROI

To market their services to prospective partners, especially payers, networks must determine 

their value proposition. How would an MCO benefit from purchasing SDOH from a CIHN? How 

would those services improve outcomes? What would the cost savings be?

While there are tools for calculating ROI, the tools alone are not enough. The inputs to those 

tools must be evidence-based. For example, how might nutrition assistance services help avert 

unplanned hospitalizations due to diabetes-related complications? There is a growing body of 

evidence that SDOH services produce ROI, but the evidence base remains incomplete. CIHNs 

will need to track this evidence base as it grows and incorporate it into their stated value 

proposition to be as concrete and persuasive as possible when negotiating with payers.

Preparedness to Partner

Networks must actively pursue engagement with state Medicaid agencies before those 

agencies contract with MCOs to help influence the terms and conditions of the contracts that 

Medicaid agencies eventually execute with these organizations, such that MCOs have a strong 

incentive – if not an outright requirement – to provide the kinds of social care services that 

networks can provide.

To partner with health systems and health plans, NLEs and their networks must be prepared to 

respond to Requests for Proposals for social services when they are released. To position 

themselves to enter such arrangements, NLEs must assess their preparedness internally 

beforehand – ideally, well before they contemplate responding. NLEs should conduct these selfassessments on a repeated basis that allows them to identify their strengths and weaknesses

and incrementally improve in areas that require attention. Preparedness does not fall to the 

NLE alone. Indeed, NLEs must evaluate the stability of the CBOs in their network. Otherwise, as 

the entity that holds the contract with a health plan or health system, the NLE places itself at 

risk of failing to meet its contractual obligations.

Accountable Financing

Networks must shift their financing models from strict fee-for-service models to models that 

spread risk between networks and partners. One such risk-shifting model is value-based or 

performance-based purchasing, with networks being rewarded for creating positive outcomes 

among consumers and penalized for failing to prevent adverse outcomes.
ACL Business Acumen Summary Report |September 18, 2020|p. 22

Performance-based models are fundamentally rooted in accountability. To base their funding 

on performance, networks must have a realistic sense of whether their services can produce 

the outcomes against which their performance is measured. In other words, do their services 

meet the necessary quality standards? And if not, how might they improve the quality of those

services?

Systems and Data Interoperability

CIHNs cannot function without health IT systems that track consumer needs, referrals, followups, and outcomes, at minimum. Likewise, networks cannot expect to partner with payers 

without being able to share data, whether on a common platform or across platforms. 

The sheer number of health IT platforms has grown dramatically in recent years, along with 

interoperability standards such as HL7. Networks must grapple with this rapidly changing 

landscape. Moreover, networks must remain alert to the pitfalls of adopting the purpose-built, 

proprietary systems that some health plans or systems may demand. Becoming locked into one 

platform or standard can impair a network’s ability to contract with other payers in the future. 

The fragmentation of standards can also impede efforts to scale networks from local contexts

to regional or nationwide levels. Network A and Network B may be geographically adjacent, but 

if the two networks have adopted different platforms that cannot communicate, they will have 

a hard time knitting their networks together.

At a minimum, systems must be able to transmit data bi-directionally. In other words, they 

must be interoperable. In the absence of interoperability, individual networks may find 

themselves at a disadvantage, and plans to create networks of networks may be unachievable.

Federal and State Roles

CIHNs do not exist in a vacuum. They have relationships with the federal and state entities that 

fund and regulate them. Successful network development depends on NLEs and their partner 

CBOs having productive relationships with these entities, whether directly or (in the federal 

case) indirectly through state partners. To overcome all of the challenges listed above, state 

agencies will need to work closely with networks at different stages of development, from 

early/emerging to mature/high-functioning. For example, state agencies can work with 

networks to make full use of funding flexibilities. Medicaid agencies, for instance, can support 

networks by using HCBS waivers and Medicaid State Plan options to claim federal match for 

services and administrative activities that the state alone would otherwise be responsible for.

Federal agencies, for their part, will need to offer ongoing support, including funding 

opportunities, technical assistance, and guidance to networks directly, to state agencies, or to 

both. By helping to educate state agencies and local network partners and by creating or 
ACL Business Acumen Summary Report |September 18, 2020|p. 23

encouraging standards, federal agencies can help promote the development of individual 

networks and facilitate the growth of networks over time into a nationwide network of 

networks that can offer social services to people wherever they live.

Shared Principles and Goals

As efforts to further establish and develop CIHNs continue, it is important to understand 

guiding principles for this work. These principles were developed, tested, and refined based on 

input from CBOs, health plan and health system leaders, and all attendees of the National 

Summit on Health Care and Social Service Integration. The overarching principle guiding all 

work is ensuring that stakeholders use a person-centered approach to the integration of health 

care and social services. Doing so help partners achieved the shared goals of trust, leadership, 

accountability, sustainability, and innovation. 

Table 4 reflects the shared principles and goals emanating from the collective work of ACL, 

stakeholders, and Roundtable and Summit participants.

Table 4. Shared Principles and Goals

Overarching Principle: Use a person centered approach to integrate health care and social 

services.

Principle Description

Trust Uphold and preserve the confidence and respect of individuals.

Leadership Co-lead and coordinate holistic services.

Accountability Create a culture of performance and data driven quality improvement 

among all stakeholders.

Sustainability Advance equitable shared financing of social care and shift to risk-based 

payment overtime.

Innovation Evaluate and evolve interventions to improve service delivery, efficiency,

and outcomes.

Moving forward, these principles, and everything learned from stakeholder engagement, will 

guide ACL’s continued efforts to advance the integration of health care and social services. This 

work is ongoing in communities across the country, and ACL will support the work of all 

stakeholders and engage them in discussions to ensure that CIHNs are well positioned to 

effectively integrate services and improve the health of individuals in communities across all 

states and regions.
ACL Business Acumen Summary Report |September 18, 2020|p. 24

Appendix A: Stakeholder Engagement Activity Attendees

Enhancing Community-Based Networks for Nationwide Capacity Roundtable

Participant Name Affiliation

Connie Benton-Wolfe Aging & In-Home Services of NE Indiana

Jacob Reider Alliance for Better Health

Brianna Brennan Alliance for Better Health

Kathy Vesley-Massey Bay Aging

Sharon Williams Consultant

Abigail Morgan Direction Home Akron Canton

Jennifer Raymond Elder Services of the Merrimack Valley

Tim McNeill Freedmen’s Health

Paula Johnson Houston Area Agency on Aging

Janice Sparks Houston Area Agency on Aging

Jen Morgan Center for Persons with Disabilities, Utah State University

Richard Petty Independent Living Research Utilization

Brooke Curtis Independent Living Research Utilization

Mary Kaschak Long-Term Quality Alliance

Leigh Ann Eagle MAC, Inc.

Sue Lachenmayr MAC, Inc.

Lucy Theilheimer Meals On Wheels America

Marisa Scala-Foley National Association of Area Agencies on Aging

Karol Tapias National Association of Area Agencies on Aging

Sandy Markwood National Association of Area Agencies on Aging

Kathleen Cameron National Council on Aging

June Simmons Partners in Care

Bill Massey Peninsula Agency on Aging

Dana Eidson SARCOA (Alabama)

Rene Seidel The SCAN Foundation
ACL Business Acumen Summary Report |September 18, 2020|p. 25

Roundtable Work Group

Participant Name Affiliation

Connie Benton-Wolfe Aging & In-Home Services of NE Indiana

Kathy Vesley Bay Aging

Abigail Morgan Direction Home Akron Canton

Jennifer Raymond Elder Services of the Merrimack Valley

Marisa Scala-Foley National Association of Area Agencies on Aging

Karol Tapias National Association of Area Agencies on Aging

June Simmons Partners in Care Foundation

Jim Vandagrifft Preferred Population Health Management
ACL Business Acumen Summary Report |September 18, 2020|p. 26

Appendix B: Roundtable Work Group Paper

Community Integrated Health Networks: An Organizing Model Connecting Health Care & Social 

Services

March 1, 2020

Health care and community-based long-term services and supports have historically operated 

as separate delivery systems, with health care providers addressing individuals’ medical needs 

and community-based organizations (CBOs) addressing functional needs and social 

determinants of health (SDOH). The lack of coordination between these equally important – but 

siloed – systems leaves the individuals who use them – older adults, individuals with disabilities, 

and caregivers – with the burden of navigating different service systems, leading to confusion, 

stress, and a higher probability of institutional care and related costs.

In this paper, we make the case that integrating these systems into community integrated 

health networks leads to better outcomes and lower costs. In addition, we describe a set of CBO 

network models, ranging from a local/regional level to a national level. These networks of CBOs 

operate at different levels and formalize contractual relationships with health care partners 

according to their size, capacity, population needs, and geographical reach.

Preamble: The Guiding Principles of the Organizing Model

The goal of the organizing model presented below is to promote a person-centered approach to 

integrating medical and social care in which the individual’s preferences, goals, and interests 

are embedded across various services and touch points. It draws heavily from input provided by 

a work group of participants who attended the Enhancing Community-Based Networks for 

Nationwide Capacity Roundtable Meeting at the Washington, DC offices of the Administration 

for Community Living (ACL) on December 5, 2019. Following the Roundtable meeting, a subset 

of community leaders who have been developing networks over the last decade agreed to meet 

on a biweekly basis to further refine an organizing model for connecting health care and social 

services. 

The Roundtable Work Group was guided by the following set of core principles on community 

integrated health networks:

1. Trust: Networks leverage established relationships in the community and in the home to 

ensure that individuals feel understood and supported.

2. Leadership: Social service and health care decision makers share leadership 

responsibilities in planning and managing social assessments, referrals, service delivery, 

and team-based, holistic care.
ACL Business Acumen Summary Report |September 18, 2020|p. 27

3. Accountability: Social service leaders implement a system of accountability and quality 

improvement at all levels using agreed-upon performance benchmarks, frameworks for 

data sharing and regular reporting, and data-driven strategies for improvement.

4. Sustainability: Networks finance services that address SDOH through multi-payer 

arrangements that build community capacity. Over time, they transition from a fee-forservice payment model to value-based/risk-based payment models for delivering social 

services in comprehensive, coordinated care environments.

5. Innovation: To maximize efficient delivery of services and health outcomes, networks 

implement, evaluate, and iterate evidence-based interventions and innovative care 

models.

Why Do We Need Community Integrated Health Networks?

A growing body of literature shows that CBOs are more likely to successfully expand their 

mission to support the diverse needs of individuals and families in the community if they belong 

to integrated networks with diverse partners. These studies offer crucial insight into why it is 

important to design and replicate effective approaches for network organization.

In a study of Accountable Care Organizations (ACOs), which have become early adopters of 

efforts to integrate medical care and SDOH, Murray, Rodriguez, and Lewis (2020) found that 

ACOs were often hampered by not being well-integrated into CBO networks that have already 

developed the capacity to address SDOH. They concluded that ACOs are more likely to succeed 

in integrating SDOH into their broader efforts if they implement local and regional networking 

initiatives that connect them to CBOs. They further concluded that such integration would also 

be improved by providing sustainable funding and developing standardized data on CBOs’ 

services and their quality.

In one study, Brewster, Brault, Tan, Curry, and Bradley (2018) studied 16 Hospital Service Areas 

(HSAs) that performed either well or poorly across three key outcomes: ambulatory carerelated hospitalizations; readmission rates; and average reimbursements per Medicare 

beneficiary. Using site visits and in-depth interviews with nearly 250 representatives of health 

care organizations, social service agencies, and local government bodies, they found that 

organizations in the high-performing HSAs collaborated more deeply and consistently with 

CBOs that provided social services than those in the low-performing HSAs.

In a separate study, Brewster, Kunkel, Straker, and Curry (2018) found that counties whose 

Areas Agencies on Aging (AAAs) maintained informal partnerships with a broad range of 

organizations in health care and other sectors had significantly lower hospital readmission 

rates, compared to counties whose AAAs had informal partnerships with fewer types of 
ACL Business Acumen Summary Report |September 18, 2020|p. 28

organizations. Moreover, counties whose AAAs had programs to divert older adults away from 

nursing home placement had significantly lower avoidable nursing home use, compared to 

counties whose AAAs lacked such programs.

In a third study, Brewster, Yuan, Tan, Tangoren, and Curry (2019) explored the characteristics of 

effective collaborative networks. They collected survey data on collaborative ties among health 

care and social service organizations in 20 communities with high or low performance on 

avoidable health care use and spending by Medicare beneficiaries. They measured six types of 

ties: collaboration; referrals; information sharing; project cosponsoring; financial contracting; 

and joint needs assessments. Two features distinguished high-performing networks from lowperforming ones: 1) health care organizations occupied more central positions (meaning they 

had the densest array of connections to other organizations); and 2) subnetworks of cosponsorship ties were more cohesive (specifically, denser and more centralized around 

activities such as client referral and needs assessments). AAAs tended to be more central than 

any other type of organization because they are already positioned as network brokers and can 

thus serve as anchors for new networks of CBOs within HSAs.

The findings of these studies suggest that efforts to improve medical outcomes and lower costs 

by addressing SDOH will be more effective if CBOs, health plans, and health systems develop 

formalized partnerships within collaborative networks. 

How Might Community Integrated Health Be Organized?

How should CBO-led networks be organized? To answer that question, we first define 

community integrated health networks as a coordinated group of visible and trusted CBOs led 

by a NLE that have entered a formal partnership with a health care organization. Headed by 

NLEs, community integrated health networks are scalable and can offer one-stop contracting 

for multiple proven interventions and services. These interventions can be conducted in an 

individual’s home and in a person-centered fashion by a workforce trained in person-centered 

thinking, planning, and practice. These networks may benefit from using a centralized, 

coordinated model for service provision, administrative functions, and quality improvement. 

The NLE, which serves as the hub for coordinating the services of the wider network, provides a 

unified and consistent approach to program delivery across a geographic area. It can also 

provide administrative oversight and take the lead in governance responsibilities.
ACL Business Acumen Summary Report |September 18, 2020|p. 29

Establishing community integrated health networks led by NLEs gives these networks the 

capacity to:

· Deliver a broad scope of SDOH services

· Expand and evolve populations served by reaching more diverse consumers and 

traditionally hard-to-reach populations

· Build stronger administrative infrastructures

· Capitalize on economies of scale

· Provide expanded geographic coverage at various levels – community (within states), 

statewide, regional (across state lines), and national (multi-state)

· Offer one-stop contracting for multiple services with different payers

· Expand quality improvement initiatives and successes

A NLE allows private health care entities to efficiently contract with multiple community-based 

service organizations in a streamlined way. In response to health care payers across the 

country, NLEs can leverage existing national aging and disability networks. NLEs are rapidly 

forming new legal and organizational structures to help streamline and coordinate payments, 

implement a consistent referral and service delivery process, manage data flows, expand 

geographic coverage, and improve risk management. A significant advantage of NLE-led 

networks is their capacity to provide services at different geographic levels, such as 1) 

community-wide; 2) statewide; 3) regionally across state lines; and 4) national models across 

multiple states to meet the market demand of health plans’ and systems’ geographic footprint.

Because community integrated health networks can include public and private health systems 

and health plans, they have the power to serve individuals with complex medical, social, and 

functional needs, independent of the health plan in which they are enrolled or the health 

system through which they typically receive their medical services. In addition, as a majority of 

payers shift to value-based care, a NLE can contract with all willing and interested payers and 

providers in a given market that can share in the investment needed to evolve and sustain the 

community integrated health network. These networks can also evolve their approach to 

targeting populations in need based upon individual assessments and population level analytics 

and grow network capacity and service delivery to meet these needs accordingly.

An example of an existing community integrated health network appears in Appendix A. It 

illustrates how one network, VAAACares, has used the NLE model to bring together CBOs and 
ACL Business Acumen Summary Report |September 18, 2020|p. 30

health partners to improve outcomes for the individuals they serve while adhering to the key 

principles listed in the preamble of this paper.

Which Services Do Community Integrated Health Networks Offer?

According to a recent national 

request for information (RFI) 

survey by the Aging and Disability 

Business Institute (Kunkel, 

Wilson, Lackmeyer, and Straker, 

2019), the most common health 

care contracting partners for 

CBOs (AAAs, CILs, and others) are 

Medicaid managed care 

organizations (MCOs), followed 

by state Medicaid plans and 

hospitals and hospital systems, 

respectively. Through a recent 

shift in the CHRONIC Care Act, 

CBOs are also beginning to 

partner with Medicare Advantage 

plans with such partnerships continuing to grow. The same survey revealed that nearly 250,000 

individuals were served through contracts with health care partners, and 85 percent of 

respondents indicated that their contracts targeted high-risk or high-need groups. Finally, the 

RFI survey also found that the most common services provided under contracts were 

community home-based case management, care coordination, and service coordination.

Figure A. Percentage of CIHN Contracts Offering Various 

Services, Based on RFI Survey

Citation: Kunkel, Lackmeyer, Stracker, and Wilson (2019)

Community integrated health networks may offer a basic set of services. These commonly 

offered services could include those listed in the graphic below.
ACL Business Acumen Summary Report |September 18, 2020|p. 31

Figure B: Services That Community Integrated Health Networks Might Commonly Offer

Note that the services listed above do not represent an exhaustive list.

Community integrated health networks may also offer other types of services. The set of such 

services could depend on network capacity, the needs of the communities they serve, and 

demand from payers (including the willingness to pay a reasonable price). These other services 

could include those listed in Figure C.

Figure C: Services that Community Integrated Health Networks 

Might Offer Depending on Local Need and Demand

Again, the services listed above do not represent an exhaustive list.
ACL Business Acumen Summary Report |September 18, 2020|p. 32

Conclusion

We have presented a brief review of the benefits of network integration and suggested ways 

that community integrated health networks led by NLEs might be organized at different 

geographic scales. We have also enumerated services that we believe community integrated 

health networks may commonly offer, along with services that such networks may offer less 

commonly, depending on capacity, the needs of the community, and demand from payers.
ACL Business Acumen Summary Report |September 18, 2020|p. 33

Appendix A: Example of Community Integrated Health Network, VAAACares
ACL Business Acumen Summary Report |September 18, 2020|p. 34

Appendix B: Glossary of Abbreviations

Acronym Meaning

AAA Area Agency on Aging

ACL Administration for Community Living

ACO Accountable Care Organization

CBO Community-Based Organization

CIL Center for Independent Living

HSA Hospital Service Areas

MA Medicare Advantage

MCO Managed Care Organizations

NLE Network Lead Entity

RFI Request for Information

SDOH Social Determinants of Health
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 35

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Foundation. Retrieved from https://www.picf.org/partners-at-home-network/
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 37

Appendix C: National Summit on Health Care and Social Service Integration 

Sessions 

Table C-1. Vision for the Future

Main Theme The main theme of this session was that function drives Medicare and 

Medicaid spending, and stakeholders need models that address this fact. 

Moreover, stakeholders need alignment across payers, sustainable 

investment, and a nationwide CBO network to create a better model for 

screening, risk, and accountability sharing. One way to build out 

infrastructure and increase cross-payer alignment is to have social service 

professionals act in new “triage” roles that would help address barriers 

without putting undue burdens on clinicians.

Opportunities · The need to invest sustainably.

· The need to align payers across incentives and regulations.

· The need for CBOs to look at the overall cost at the individual level and 

use that to make the business case as to why care delivery is important.

· At the local level, referrals, quality monitoring, and reporting require 

standardization.

· A shift in thinking in terms of competition to thinking in terms of 

cooperation in needed.

· For their part, CBOs must ensure they are educating their state partners.

Actions · Create a better model to address functional limitations.

· Develop standardized data systems and interoperability protocols so that 

moving to a network of CBOs is more feasible.

· Create a systematic screening process.

· Create “social work triage” as a specific role to help address barriers to 

care without putting undue burdens on clinicians.

· Craft a plan for providing services to individuals with are dually eligible 

for Medicare and Medicaid, including how to manage the associated 

payment complexities.

· CBOs must find a way to communicate regularly and clearly with health 

plans and health systems.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 38

Table C-2. Current State of Health care and Social Service Integration

Main Theme This session reviewed the current state of partnerships between health care

and CBOs, and what assets/resources are collectively needed to reach the 

desired future. One way to move forward is by leveraging emerging payment 

and technology opportunities, including the need for collaboration across 

payers and providers for sustainable, community-wide integration of 

services.

Opportunities · In 2018, there were 10 states that showed no evidence of network 

development. It is important to work with those 10 states to build 

networks and the capacity to provide the most commonly provided 

services.

· Without policy opportunities or policy guidance, health markets may not 

interoperate.

Actions · Continue to use business intelligence to build and strengthen 

partnerships between CBOs and health plans and systems so that 

everyone has access.

· Look at consolidating the 20,000 aging and disability service providers, 

AAAs and CILs, to have an organized network with optimal service 

delivery.

· Health plans and health systems should work with CBOs in to learn from 

them and teach them more about value-based payment models.

Table C-3. Shared Goals and Principles

Main Theme In this session, ACL conducted live polls of the five key attributes of a 

successful CIHN: trust, leadership, accountability, sustainability, and 

innovation. Summit participants expressed overall agreement on the 

importance of individual principles, all of which scored above a 4.1 on a 

Likert scale (where 1 was “strongly disagree” and 5 was “strongly agree”). 

However, strong opinions were raised about the narrow framing of 

accountability; the narrow view of which parties are involved in financing; 

and the negative connotations of the word “leverage.”

Opportunities Review the audience feedback captured electronically during this session to 

see what changes might be made to improve these principles.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 39

Actions · Revise the definition of Accountability to incorporate a focus on the 

community.

· Broaden the scope of financing opportunities to incorporate all 

stakeholders and partners.

· Incorporate both private and public sector investments in the social 

system.

· Revise the language to avoid the use of the word “leverage.”

· Develop a set of concrete next actions steps.

Table C-4. Lunch and Fireside Chat Plenary

Main Theme The Centers for Medicare and Medicaid Services, Center for Medicare and 

Medicaid Innovation (CMMI) would like to see more partnerships between 

community-based organizations (CBOs) and payers. CMMI needs more data 

about decision-making for accountable care providers, community 

resources, and connecting individuals with services and outcomes to 

determine where to invest and who to partner with to maximize return on 

investment (ROI).

Opportunities · There is an urgent need to determine how to leverage data to target 

populations with the right services in the right place at the right time –

and thereby maximize ROI.

· A promising course of action is to engage Medicare Advantage plans to 

partner with CBOs to target individuals based on socioeconomic status, 

specific health conditions, or other SDOH.

· CMMI can directly or indirectly engage, but the bar for making new 

investments is high. A crucial first step is to accumulate an evidence base

that enables stakeholders to know which populations to target and how 

to target them.

Actions CMMI and its partners should consider taking steps to:

· Better understand the gaps and opportunities across siloed systems.

· Describe the kinds of data they wish to collect.

· Develop a set of standardized patient assessment data elements.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 40

Table C-5. Key Opportunities for States to Advance Social Determinants of Health

Main Theme State Aging, Disability, and Medicaid leaders can leverage existing policies 

and authorities to advance the integration of medical and social care 

through CIHNs.

Opportunities · State Medicaid directors are currently looking for more clarity around 

what they can do with 1915(c) waivers.

· State Medicaid directors should think about ways to collect high-quality 

data on service utilization and costs so they can lower costs and improve 

outcomes.

· Turnover rates among state staff can be high. To reduce turnover, state 

agencies can cultivate relationships that allow them to work together on 

a common problem.

· Continue dialog around who would pay first in a multi-payer system, 

learning from what Medicaid agencies have done in the past.

Actions · Develop an overall state framework as well as state-specific frameworks 

to help state leaders understand the local service delivery system, 

resources, policies, and services.

· Develop or improve data sharing and data exchange. At the same time, 

develop a deeper understanding of laws, rules, and protocols regarding

data privacy and security.

· Given the high numbers of people usually on waitlists to receive 

community LTSS, states should think creatively about ways to generate 

new revenue sources to serve more people.

Table C-6. Breakout Session: Scaling Networks of CBOs

Main Theme Significant resources are needed to evolve and expand CIHNs. Shifting 

towards a value-based environment is important, although fee-for-service 

models should also be given careful consideration. This shift could help 

networks move quickly on several fronts:

· Develop networks at all levels

· Align data at all levels

· Use advocacy efforts to maintain momentum

· Determine common processes that can be applied across different types 

of partnerships 

· Promote needed investment from the Department of Health and Human 

Services (HHS), especially ACL and CMS, as well as state agencies
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 41

Opportunities · Network development all levels

· Network data alignment at all levels

· Joint efforts with advocacy groups

· Necessary investment from HHS, including ACL and CMS

Actions · Develop processes and systems for credentialing and quality monitoring

· Develop readiness assessments across network partners

· Lead or join a network

· Share best practices to identify solutions for new populations

· Tie Health care Effectiveness Data Information (HEDIS) scores to aspects 

of network development and maturity

Table C-7. Breakout Session: Technology Enablers and Barriers

Main Theme The path toward action in the domain of IT has four steps in a continuous 

process (the “Four A’s”):

1. Acquire data

2. Aggregate data

3. Analyze data

4. Act on the findings

Technology – including health information exchanges (HIEs) – enables 

organizations to take patient records and follow their status and understand 

their clinical needs. There are five major barriers to adopting technology that 

would facilitate interoperability:

1. Limited interoperability

2. Data complexity

3. Translating use of health data into ROI

4. Sustainability

5. Lack of consistent standards
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 42

Opportunities · Promote interoperability

· Capture and maintain patient consent

· Develop infrastructure throughout the network

· Promote closed-loop referrals

· Incorporate HIE into a more general view of infrastructure needs

· Resolve the confusion that arises from competing application-program 

interfaces (APIs) for different systems

· Focus on interoperability from hub to hub (NLE to NLE)

· Collect data not only from medical sources, but also from behavioral and 

social networks, with data traveling bi-directionally

· Tie data to payment

· Explore standards such as HL7 referral standards

· Favor standards that are technology agnostic

· Catalog current best practices, as the Office of the National Coordinator 

(ONC) did in 2015

Actions · Identify and promote best practices

· Create easy integration

· Promote discussion among providers, payers, technology vendors, and 

organizations that set technology standards

Table C-8. Breakout Session: Federal and State Roles

Main Theme State Units on Aging (SUAs) should engage more fully in developing policy 

and designing conversations to support the development of these networks. 

As states expand their work in this area, SUAs should collaborate actively 

with all agencies and stakeholders.

Opportunities · SUAs should get AAAs more involved in Business Acumen training, 

recognizing that there are internal changes that may need to happen to 

stay involved in the development of these networks. This training may 

help AAAs improve their capacity to negotiate on their own behalf.

· Across the suite of programs it funds, states can require that recipients 

of those funds work with CBOs, thus giving CBOs an opportunity to 

demonstrate they could do the work.

· SUAs should be involved in developing policy – aligning the work across 

agencies so that they avoid confusing, misaligned guidance going out to 

the CBOs.

· States should support the necessary IT and data analytics.

· SUAs should work with state Medicaid agencies to develop strategies for 

providing joint support to CBOs.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 43

Actions · Clarify roles (funding, regulations, oversight, policy, etc.) by bringing 

together entities to determine who is responsible for what and how 

every organization can maximize funding and revenue.

· Seek clarification from federal partners that fund states, especially ACL 

and CMS, and request additional guidance when needed.

· SUAs should ensure that they are fully accountable for the funding they 

receive and are compliant with relevant laws and regulations.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 44

Table C-9. Breakout Session: Financing Social Care

Main Theme Specific, replicable best practices and opportunities exist to promote the 

integration of medical and social care. These integration practices should be 

promoted by data analytics teams, contractors, health care economists, ACL, 

CMS, and state Medicaid agencies.

Opportunities · With guidance from CMS on how these practices could be implemented 

under the current regulatory framework, providers would be more likely 

to replicate these practices.

· CBOs continue to encounter difficulties demonstrating the ROI of their 

services; to contract with payers such as MCOs, they will need help 

overcoming this barrier.

· One step toward demonstrating ROI is for CBOs to differentiate their 

products.

Actions · Develop a care delivery system to address SDOH that will be sustained 

through the capture of reimbursement from multiple payers.

· One best practice might be a system that triggers reimbursement from 

heath systems and health plans for care management services.

· Work with CBOs to calculate the ROI of their services and sell their 

market value to prospective purchasers (Medicaid and Medicare claims 

data may be a useful source of data).

· Use Medicaid and Medicare dollars to finance infrastructure and/or 

social services.

· MCOs and CBOs need to communicate clearly so that each understands 

that the other is a partner, not a competitor.

Table C-10. Bringing It All Together

Main Theme This session concluded the Summit, highlighting the main themes of the day 

and outlining potential next steps. Key themes included state policy 

frameworks, working across payers, and the sustainability of network 

efforts.

Opportunities · Use existing assessment tools, the social service workforce, and 

evidence-based practices to build out a curriculum for CBOs.

· Outline the subset of social interventions that will generate the highest 

ROI.

· Develop frameworks for states to share resources with each other.

· Identify which one-time investments need to be made up front and 

which can be deferred.
Business Acumen Summary Report | Mission Analytics Group | April 10, 2020 | p. 45

Actions · Advocate for state policy frameworks that incorporate the Aging 

Network’s mission.

· Develop frameworks for sharing resources.

· Clarify the pathway to addressing SDOH through CBOs.

· Provide guidance on how all stakeholders can work together to achieve 

the best outcomes.