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State-Community Collaboration Think Tank – Strategies for CBO Development to Address SDOH: Key 

Considerations

This document seeks to support state agencies and Network Lead Entities (NLEs)1 through a collaborative process to address social determinants 

of health (SDOH) in their state and local regions. Below are a series of steps and questions for consideration for state and local-level partners

(i.e., NLEs) to highlight perspectives, promote information sharing, and foster communication through community-based organization (CBO)

network growth. In this document, state partners represent leadership from state agencies whereas local-level partners may represent a 

regional area, have a statewide reach or multi-state region. The creation of this resource was informed by the activities under the StateCommunity Collaboration Think Tank sponsored by the Administration for Community Living. 

1 The Network Lead Entity serves as the hub for coordinating the services of a wider network, providing a unified and consistent approach to program delivery 

across a geographic area, administrative oversight, and overseeing governance responsibilities.
 

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Step 1: Needs assessment to identify and prioritize SDOH activities

State and NLE partners need a comprehensive understanding of a variety of factors, including: the overall health and social services 

landscape, the opportunities for integration of health and social service providers, opportunities for leveraging the state’s No Wrong Door 

(NWD) system, the needs and preferences of community members and the types of services available or needed in order to address those 

unique needs, and the health care demands at multiple levels across the state (statewide, regionally and locally). Example resources to 

better understand the landscape include: Health Department statistics, Planning District needs prioritizations, hospital needs assessments, 

CBO or Area Agency on Aging (AAA) needs assessments or other surveys, long term services and supports (LTSS) system reform plans or 

other state reports related to home and community-based services (HCBS) or LTSS, local health care utilization reports, and local program 

evaluation reports or studies.

While state agencies may embark on SDOH-specific strategic planning efforts, agencies also identify statewide SDOH priorities through other 

existing planning efforts such as within components of state plans for aging or state “master plans.” NLEs are encouraged to understand the 

state’s SDOH priorities and overarching NWD system components. Identifying commonalities fosters a natural opportunity for collaboration 

on strategies, activities and solutions. Through discussions with health care entities and other partners, NLEs may identify additional regionspecific priorities as well. 

Questions for States Questions for NLEs

Ex.

• Are there existing policies to address SDOH in your state? If so, 

what are those policies, how were they created, and how do 

they align with the state NWD system? 

• What contracts and mechanisms does your state have in place 

related to health and health outcomes? Related to SDOH? 

• What state agencies are responsible for addressing SDOH? 

Does your agency have established ways to collaborate with 

these agencies? 

• What data does your state have access to?

Ex.

• How does your current network development strategy include 

consideration of state or regional SDOH needs/priorities? Of the 

state NWD system access functions?

• What contracts and mechanisms does your state have in place 

related to health and health outcomes?

• Who is currently doing work in this space? Who should be involved 

to understand/explore that landscape?

• How does your network identify and address the unique and local 

needs of your community? 
 

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• What data do local sites collect that they can share for SDOH 

strategizing?

• What work is already ongoing in your state in this space? Who 

is doing it? 

• What data around unmet needs does your network currently have 

access to? What data does your network need? 

• How does your network demonstrate your skills, knowledge and 

experience in serving various communities?

• Does your network’s strategic plan include goals around 

addressing SDOH?

Step 2: Identify and engage stakeholders

The variation under SDOH requires a diverse stakeholder network at both the state and local levels. State-level stakeholder engagement is 

approached through a broad lens with strategic advisors representing state NWD system including public agencies, public and private 

partnerships, local CBOs, and consumers of services. The overall strategic direction from these state-level advisors offers guidance to their 

local-level counterparts. NLEs may consider conducting stakeholder interviews or convening a VIP stakeholder group to further understand 

partners’ needs and interests.

An evolving partnership will progress from stakeholder advisement to stakeholder investment such as directives specific to contracting which 

require policies, practices or partners. Stakeholders should understand the strategic “business case” behind the integration of health and 

social care and leveraging the existing CBO network, and overarching NWD system, readily available to provide services. 

Stakeholder engagement and a diverse network is important at all levels: local, regional, statewide and cross-states. A local outreach and

partnership strategy that includes health care entities and peer community-based organizations/direct service providers will produce a 

network prepared to address the local SDOH priorities identified in Step 1. 

Questions for States Questions for NLEs

Ex.

• When comparing the SDOH priorities from Step 1 and the 

landscape of potential partners, are there new partnerships to 

build? 

• Do your partners work with others who can join your 

stakeholder work? 

• Is there an opportunity to integrate SDOH into other state 

activities and/or collaborate with other state partners 

(Medicaid, Transportation, Housing, Technology, etc.)?

Ex. 

• Who are your current partners at the state level (NWD contact, 

Medicaid, etc.)? How can they support your outreach efforts or 

relationship strengthening efforts at the local level? 

• Who are your current partners at the local level? 

• What other stakeholders share your network’s goals around 

addressing local community needs around SDOH?

• Who are the providers who can address the SDOH priorities 

identified by your local efforts in Step 1? Are they currently your 

partners? 
 

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• How do you currently inform stakeholders about your SDOH 

work, including NWD system access functions? 

• How are local level agencies and consumer voices informing 

your stakeholder engagement activities? 

• How is the perspective of technology or identification of 

technology needs represented in your stakeholder groups? 

Step 3: Conduct strategic planning to establish goals and benchmarks and to develop an implementation plan

While state-level agencies identify opportunities to use NLEs as regional levers or identify other approaches to address the state’s SDOH

priorities, NLEs and their stakeholders will determine their network goals, benchmarks, and implementation strategies to address their SDOH 

priorities. 

NLEs may use the state guidance from Steps 1 and 2 to inform objectives and ask state partners about access to data sources to support 

benchmark setting for measurable goals. States may plan priorities (including funding) to work towards supplying interoperable data 

including health and SDOH to track for outcomes. Access to data empowers NLEs and their stakeholders to perform a continuous quality 

improvement process through tracking and reviewing results in a routine manner. Possible resources to consider as NLEs establish 

measurable benchmarks and implementation strategies include: local-level IT/MIS databases for HCBS, LTSS and SDOH service providers, 

state agency databases, and/or programmatic surveys and reports. 

Questions for States Questions for NLEs

Ex. 

• Which agencies collect demographic and social need related 

data? 

• What data sources exist that you have access to? 

• What is your state’s capacity to aggregate local data?

• What (local or aggregated) data is impactful for showing NLE 

impact? 

• How does the NLE / local plan support the state’s goals? 

• Are there existing data use agreements for sharing of data that 

can be applied to the NLEs? Can one be created? 

Ex. 

• Is there an existing strategic plan that could be revised/updated 

to incorporate goals/strategies around SDOH? 

• What steps can you take to further align your work with state 

SDOH priorities and NWD access functions? 

• Are there specific measurable objectives linked to the growth and 

sustainability of your NLE?

• What data do your stakeholders/partners have access to that are 

shareable with you (through a formal agreement, if needed)? 

• Are there successful strategies from other programs, evaluations 

or reports that are applicable and/or can be integrated into

approach? 

• Does your agency and/or partner organizations collect data that 

could inform strategic planning efforts?
 

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Step 4: Implement plan and apply lessons learned to continue CBO and network development

Before carrying out the implementation plan and strategies from Step 3, formal agreements, contracts, or memorandums of understanding 

(MOUs) will be necessary to understand stakeholder roles, coordination of services, data sharing, and payment structures. Tracking and 

regularly reviewing data (weekly, monthly, or quarterly) with stakeholders is key to a continuous quality improvement process. The data 

review highlights what is or is not working and creates an opportunity to refine implementation strategies and improve service delivery. The 

importance of tracking results applies to both state and local level partners. 

As NLEs continue to refine their strategies and track improvement data with stakeholders, any lessons learned can be shared with peer NLEs 

for capacity building. The NLE data to be shared can include inputs and outcomes to track growth and contract performance. NLEs can use 

the data for business development purposes to grow their service network, refine service delivery within the network, and expand reach to 

address SDOH needs through new health care partnerships. 

State agencies may share improvement data or lessons learned broadly across their state, with state peers, and federal partners. Overtime, 

state agencies and NLEs will need to revisit planning efforts in Steps 1 and 2 as the health and social services landscape continues to evolve. 

Questions for States Questions for NLEs

Ex. 

• Is your state currently implementing any of the strategies 

outlined in the Strategic Framework Call to Action? 

• Does your state have data sharing agreements with your local 

partners? 

• What communication will be needed during implementation? 

And to whom?

• What data are you reviewing and what is that process? Who 

reviews the data and at what frequency? 

• What (local and/or aggregated) data is impactful for your 

stakeholders for understanding SDOH needs? How should it be 

shared and at what frequency? 

• What (local or aggregated) data is impactful for showing NLE 

service impact? How should it be shared and at what 

frequency? 

• How will you evaluate progress?

Ex. 

• What resources or mechanisms are available to track progress 

related to SDOH strategies and goals? 

• How will you monitor progress and track growth (frequency and 

what data)?

• Are there data sharing agreements at the state level you can 

leverage? 

• How will you monitor contract performance (frequency and what 

data)? (ie quality and performance goals are continually 

monitored and as appropriate, modified to enhance network 

capabilities)

• How will data and results be shared with stakeholders and state 

partners? 

• What program/service data is most valuable to your NLE for new 

stakeholder engagement? For current stakeholder engagement? 
 

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• Are there lessons learned from other SDOH levers that can be 

shared or applied to NLEs (or vice versa)? 

• What aggregated state-level data is valuable to your NLE and 

stakeholders? How should it be shared and at what frequency? 

• Do your current strategies support your NLE sustainability? 

• What lessons learned can be shared with peer NLEs or state 

partners?