ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 1

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.
ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 2

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

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 Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 3

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 Network Lead Entity (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.

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
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· 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 

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

principles listed in the preamble of this paper.
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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.

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

offered services could include those listed in the graphic below.

Citation: 1 Kunkel, Stracker, Kelly, and Lackmeyer (2017)
ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 6

Figure 1: 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 on page 6.

Figure 2: 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 Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 7

Conclusion

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

that community integrated health networks led by network lead entities 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.

If You Have Feedback on This Paper

If you have feedback on this draft of the paper or wish to connect with a community network, 

you may email the Administration for Community Living at CommunityNetworks@acl.hhs.gov.
ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 8

Appendix A: Example of Community Integrated Health

Network, VAAACares
ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 9

Appendix B: Glossary of Abbreviations

Acronym Meaning

AAA Areas Agency on Aging

ACL Administration for Community Living

ACO Accountable Care Organizations

CBO Community-Based Organizations

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
ACL Business Acumen Roundtable Work Group | CBO Network Models | March 1, 2020 | p. 10

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Further Reading on Social Determinants of Health

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promoting health and health equity (p. 13). Kaiser Commission on Medicaid and the 

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