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Western New York Integrated Care Collaborative

Addressing Social Determinants of Health: 

Nutrition and Food Insecurity

A Community Care Hub Innovation Brief

May 2023

Overview of the Program

Western New York Integrated Care Collaborative (WNYICC) is a Community Care Hub (CCH) 

operating across the entire western New York region and offering a variety of services to 

support health and social needs. Services related to nutrition and food insecurity include inhome meal delivery, health coaching, medical nutrition therapy, and diabetes prevention.1

This brief provides a brief history of WNYICC and details their nutrition offerings and funding 

sources. 

Western New York Integrated Care Collaborative

WNYICC operates a network of over 50 community-based organizations (CBO) that provide 

direct services, including post-discharge meals, care coordination, medical nutrition therapy,

and evidence-based programs (e.g., Diabetes Prevention Program, Falls Prevention, Chronic 

Disease Self-Management). They host a centralized information technology (IT) platform for 

all their CBOs to document assessments for health-related social needs (HRSN), deploy HRSN 

interventions, and document the outcomes of interventions for identified HRSNs. WNYICC 

centralizes the contracting process and provides training to CBO members on the 

interventions that are currently contracted. Additionally, WNYICC implements a continuous 

quality improvement process to ensure that all CBOs provide high quality services. This 

includes program and process evaluation via a quality assurance committee. Maintaining 

such a role is core to the responsibilities of a CCH. A list of the WNYICC network members 

can be found on their website: https://www.wnyicc.org/About/Network-Members.

1 https://www.wnyicc.org/Programs

This brief is part of a series of case studies of aging and disability network organizations 

addressing the nutrition and food insecurity needs in their communities by braiding 

funding streams and forming partnerships with other organizations. These case studies 

provide examples of how high-performing organizations use a variety of funding streams 

to address nutrition, food insecurity, and other health and social needs.

WNYICC offers a variety of services to support health and social needs across the 

entire western New York region.
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Key Players

Readiness for Contracting as a CCH

WNYICC formed as a CCH in 2016 to make contracting with health care entities easier and 

more efficient for CBOs. The timeline below has details on CCH development. Multiple 

funding sources contributed to the development of the WNYICC including:

· Health Foundation of Western and Central New York

· John R. Oishei Foundation

· New York State Office for the Aging through a Chronic Disease Self-Management

Education (CDSME) program grant from the Administration for Community Living

(ACL)

· ACL: Scaling Network Lead Entities Grant

CCH’s First Contract and Evidence of Impact

WNYICC’s first contract as a CCH was a special supplemental benefit for the chronically ill 

(SSBCI) to provide post-discharge meals to Independent Health’s Medicare Advantage (MA) 

plan members. WNYICC worked with Independent Health to conduct an evaluation of the 

NY Connects is the No Wrong Door (NWD) System in New York coordinated by the New York 

Office for the Aging. Several local ADRCs participate as network member agencies in the 

WNYICC CCH including:

Allegany County NY Connects

Chautauqua County NY Connects 

Erie County NY Connects 

Genesee County NY Connects 

Livingston County NY Connects 

Niagara County NY Connects 

Orleans County NY Connects

Western New York Independent Living NY Connects 

Wyoming County NY Connects

WNYICC is a CCH operating across the entire western New York region. It is comprised of nine

NY Connects local ADRCs and 40+ other CBOs.

Entities such as Medicare Advantage plans and Medicaid Managed Care Plans pay WNYICC 

for a range of services.
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SSBCI post-discharge meal benefit to assess the impact of the meal benefit on readmissions. 

The evaluation revealed that persons with multiple chronic conditions benefitted most from 

the post-discharge meal intervention. Based on the evaluation data, Independent Health 

agreed to provide an expanded intervention that includes HRSN screening and ongoing 

health coaching.

CCH Nutrition and Food Insecurity Support

WNYICC provides a variety of support to individuals 

around nutrition and food insecurity. Their network 

provides care transitions meal support through 

contracts with regional MA health providers as 

detailed above. They provide a custom, postdischarge home-delivered meals program for 

hospitalized members that includes hot homedelivered meals and medically tailored meals. They 

also incorporate patient satisfaction surveys to 

facilitate member feedback to the health plan.

Significance of this Partnership

This work is important because of the focus on integrating community-based social service 

organizations into the delivery of healthcare to Medicare and Medicaid recipients by forming 

a CCH of CBOs. WNYICC provides a model for a sustainable alternative to grant funding for 

CBOs that also leverages staff expertise and increases organizational capacity. These 

successes can result in the expansion of contracts between healthcare payers and AAAs, 

Aging and Disability Resource Centers (ADRC), and other CBOs to provide services to address 

social needs.

Nutrition Services Provided by 

WNYICC

· Outreach

· Post-discharge home delivered meals

· Medically tailored meals

· Health coaching

· HRSN screening (food, housing,

transportation)

· SNAP outreach

The success of the contract agreement with a major · Diabetes prevention

regional MA plan allowed WYNICC to coordinate with · Diabetes self-management

hospital discharge planners and receive daily · Medical nutrition therapy

notification of member admissions to solicit referrals

and document meal delivery by their CCH through a centralized data system managed by

WNYICC.

WNYICC relies on a complex network of home-delivered meals providers, including large and

small independent meal providers, to provide meals to all regions covered by the network

(including rural areas). Some WNYICC members are Area Agencies on Aging (AAA) that also 

administer the federal Older Americans Act (OAA) nutrition services. Additionally, the 

WNYICC network of CBO partners includes United Way, Meals on Wheels, food banks, and a 

range of other community-based direct service providers serving the entire western New 

York region. Through these connections they are also able to connect individuals with public 

benefits supports for nutrition.

WNYICC’s regional service-provider network of community-based and governmental 

agencies strives to produce better health outcomes and quality of life for older adults, 

people with disabilities and/or chronic conditions, and their caregivers by providing 

comprehensive, cost-effective, and community-based integrated care.
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WNYICC is also linked with their regional Health Information Exchanges (HIE) called

HEALTHeLINK to receive Admission Discharge Alerts (ADTs) for the meal delivery program, 

verify insurance on participants, and look up clinical information on clients for programs such

as medical nutrition therapy.

Funding and Sustainability

Funding for this work includes a mix of OAA, Medicare, and Medicaid dollars. The chart 

below shows the services provided by WNYICC and the payer source.

Service2 Payer Source 

MA

Medicaid Managed Long Term 

Services and Supports (MLTSS)

Medicaid Long-Term Care (MLTC)

Type of Reimbursement 

Fee for Service (FFS)

Per Member/Per Month 

(PM/PM)

Value-Based Contract 

(VBP)

Meal delivery MA FFS

Community Health Coaching*, ** MA FFS

Diabetes Prevention Program* MA, MLTSS, Commercial VBP, FFS

Healthy IDEAS program* MA, MLTC – Launched with 2 health plans 

and a grant from the Health Foundation of 

Western and Central New York

MLTSS 

FFS, grant, VBP

Medical Nutrition Therapy* MA FFS

Falls Prevention Program*, ** MA, MLTSS FFS, VBP

Diabetes Self-Management*, ** MA, Commercial FFS

Caregiver Support Program*, ** MA FFS

*HRSN screening: Incorporated into programs assessment.

**Evidence-based health prevention workshops: included in program with wrap-around individual coaching.

2 https://www.wnyicc.org/Programs
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Timeline

HEALTH FOUNDATION GRANT

WNYICCC received a grant from Health Foundation of 

Western and Central NY to support Network Development 

and hired Nikki Kmicinski to lead this development

INCORPORATION

WNYICC was incorporated with 10 local network members

ACL BUSINESS ACUMEN LEARNING COLLABORATIVE

Local AAA and CBO leaders participated in the ACL Business 

Acumen Learning Collaborative

501(C)3 STATUS

WNYICC achieved 501(c)3 status and was approved as a 

Medicare provider

NCOA AND USAGING LEARNING COLLABORATIVES

WNYICC participated in the NCOA Medicare 

Reimbursement Learning Collaborative and in USAging’s 

Aging and Disability Business Institute’s Health Information 

Technology Learning Collaborative

GRANT APPROVALS

WNYICC was included as a sub-grantee with New York State 

Office for the Aging for an ACL CDSME grant; WNYICC was

awarded a grant from the John R. Oishei Foundation for

continued business development; WNYICC executed its first

contract with an MA Plan

IT DEVELOPMENT

WNYICC transitioned all programs, processes, and systems 

to virtual and digital processes and program delivery

ACL SCALING NLE GRANT

WNYICC was awarded ACL’s Scaling Network Lead Entities 

grant

EXPANSION

WNYICC network reaches 52 network members and has 25 

executed contracts with health plans
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Advice for Replication

Lessons learned from WNYICC experience in 

contracting include:

1. Start small with dedicated partners

and grow as you go.

2. Consider the benefits of coming

together to form a CCH, which has given rural CBOs an advantage in contracting with

health care entities that want regional coverage.

3. Collaboration is key – contracting is a partnership.

Tools and Resources

Western New York Integrated Care Collaborative Annual Report. This is the WNYICC 2021 Annual 

Report. The report audience is WNYICC's network members, however, recently the team has been 

leveraging the report as marketing material for potential health care partners.

Benefits of Joining the Network. This two-page reference from WNYICC outlines the benefits of 

joining their network. It is shared with new potential network members providing a brief overview 

of network member benefits as well as the mission, vision, and core services of the CCH.

ACL: COVID-19 Care Transitions Spotlight: Western New York Integrated Care Collaborative. This 

spotlight on the WNYICC provides information on sustaining their care transitions program before 

and during the COVID-19 pandemic.

Sustainability Spotlight: Western New York Integrated Care Collaborative Contracting for Health and 

Well-Being Coaching. This spotlight describes how WNYICC developed contracts with a Medicare 

Advantage plan to screen and address health-related social needs using health coaching codes. 

Business Acumen Case Study: Building the Western New York Integrated Care Collaborative. This 

brief authored by the Health Foundation for Western and Central New York provides an overview of 

how the CCH developed.

ACL Contracting Spotlights. This document describes the work of three CCHs, including WNYICC. 

Federal Websites

ACL No Wrong Door Webpage

ACL Community Care Hub Webpage

ACL Advancing Partnerships to Align Health Care and Human Services Webpage

ACL Nutrition and Aging Resource Center

“This work takes time so don’t be 

discouraged. Continue to tell the story and 

benefits of forming and growing your 

network, as this work is just starting.”

Nikki Kmicinski, WNYICC
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Glossary of Terms

Aging and Disability Resource Center (ADRC): ADRCs are local NWD System partners

designated by a state to provide a coordinated and integrated way for older individuals, 

individuals with disabilities and their caregivers to access LTSS. ADRCs are defined in the OAA

as networks or consortiums of AAAs, Centers for Independent Living 

(CIL), CBOs, or other entities.3

Area Agency on Aging (AAA): These agencies address the needs of older adults at the 

regional and local level through services and supports (like home-delivered meals and 

homemaker assistance) to support independent living.4

Center for Independent Living (CIL): These centers provide tools, resources, and supports for

integrating people with disabilities fully into their communities to promote equal 

opportunities, self-determination, and respect.4

Community-based Organization (CBO): CBOs in the aging and disability network are present

in every community across the U.S. and have unmatched expertise in local culture and needs;

service coordination and delivery; and securing benefits, services, and supports that

maximize independence and functioning.5

Community Care Hub (CCH): A CCH is a community-centered entity that organizes and

supports a network of community-based organizations providing services to address healthrelated social needs. A CCH centralizes administrative functions and operational 

infrastructure, including, but not limited to, contracting with healthcare organizations,

payment operations, management of referrals, service delivery fidelity and compliance, 

technology, information security, data collection, and reporting. A CCH has trusted

relationships with and understands the capacities of local community-based and healthcare

organizations and fosters cross-sector collaborations that practice community governance

with authentic local voices.

Long-Term Services and Supports (LTSS): LTSS includes a continuum of services provided in

the home and community or an institutional setting. These supports help older adults and

individuals with disabilities manage tasks that would be difficult or impossible to perform on

their own, such as personal care (e.g., bathing, dressing, and toileting); complex care (e.g., 

medication administration, wound care); home care (e.g., help with housekeeping and meal

preparation), and transportation.6

No Wrong Door (NWD): A NWD System is a network of state agencies and community-based

organizations (CBO) promoting access to LTSS through coordinated points of entry. NWD

Systems assist individuals navigating health and social care services through outreach, 

streamlined assessments, person-centered plans, information and referral to state and

community-based resources, and a governance structure that ensures these functions are

available and coordinated across the state.

3 Older Americans Act

4 https://acl.gov/programs/aging-and-disability-networks

5 https://acl.gov/news-and-events/news/addressing-social-determinants-scaling-partnerships-community-based

6 AARP LTSS Scorecard
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Authors: Christina Neill Bowen (Christina Neill Bowen Consulting, LLC); Charlene Allen 

and Kelly Cronin (Administration for Community Living); Kristen Vangeloff and Kelly 

Owczarski (The Lewin Group, Optum Serve) 

Acknowledgements: The authors wish to thank the community-based organizations who 

provided information on their nutrition activities and contracts.