The services and supports provided by aging and disability network organizations across the nation extend the reach of the health care system into the home and community and are essential parts of our health ecosystem. These organizations, including area agencies on aging, aging and disability resource centers, and centers for independent living, address many needs that improves the holistic health and independence of individuals as well as related health outcomes. They provide nutritious meals, evidence-based programs to prevent falls and self-manage chronic disease, care transitions to prevent hospital readmissions and emergency department use, personal assistance with daily activities that allow people to live safely in their own homes, and more.
Health plans and systems have partnered with aging and disability community-based organizations (CBOs) to coordinate and deliver services that address whole-person health for many years, and these partnerships are expected to increase. ACL has identified whole-person health as a strategic priority, noting a commitment to advancing approaches that integrate health care and community-based care to support independence, improve health, and reduce costs. A major part of this strategy has involved connecting networks of CBOs, led by a community care hub, to health care organizations. These partnerships are premised on the concept that when CBOs and health care organizations are well integrated, the people they collectively serve will experience better overall health, maximizing their independence and ability to live in their community of choice.
Promoting Whole-Person Health through Community Care Hubs
Community care hubs help CBOs and health care payers and providers increase a community’s capacity to address whole-person health needs. They also support the No Wrong Door (NWD) goal of increasing access to services for individuals with unmet needs. Hubs serve as a bridge between the health system and the community, often facilitating the successful transition of individuals with long-term services and supports needs who are being discharged from acute care settings back to their own homes. Community care hubs and other NWD partners serve the same population of high cost, high need individuals, regardless of whether they enter the access system via a local CBO such as an aging and disability resource center or through a health care organization.
Community care hubs centralize administrative functions and operational infrastructure. This infrastructure includes contracting with health care organizations, payment operations, management of referrals, service delivery, fidelity and compliance, technology, information security, data collection, and reporting. These organizations have trusted relationships with, and understand the capacities of, local community-based and healthcare organizations. Building the capacity of CCHs is an essential component of achieving ACL’s vision of coordinated person-centered care to address whole-person health needs for people with disabilities and older adults.
Partnering for Health at Home
Partnering for Health at Home is an ACL initiative to integrate health care and community-based providers to support independence, improve health, and reduce costs for duals and near-duals. The goal is to achieve community-clinical integration, enabled through community care hubs, to reduce total cost of care and increase the number of days spent at home vs. in a health care facility. The initiative leverages the core services provided by ACL’s network, including person-centered assessment, care coordination, evidence-based health promotion programs, nutrition programs, and care transitions.
Resources for Strengthening Community Care Hub Capacity
The resources below were developed to highlight the value of CBO networks and the services they offer, as well as encourage the expansion of these networks.
Sub-Regulatory Guidance – Contracts and Commercial Relationships under the Older Americans Act
As authorized by section 212 of the Older Americans Act (OAA), ACL encourages and supports the development of contracts and commercial relationships with health care payers and other funders, enabling the aging services network to provide more older adults with supportive, nutrition, and other services.
The guidance below was developed in response to questions ACL received from the aging services network and to clarify provisions in the 2024 OAA final rule related to section 212 of the OAA. It is intended to assist state units on aging (SUAs) and area agencies on aging (AAAs) in streamlining existing processes and developing policies and procedures to implement section 212 of the OAA. The guidance includes a sample policy and form (not required for states but as an example that could be adapted if helpful) on contracts and commercial relationships under the OAA.
Community Care Hub IT Playbook
This Community Care Hub IT Playbook is a self-guided tool on the technical and information technology (IT) infrastructure necessary to support collaboration between CCHs, the network of CBO providers, and health care partners.
The Playbook focuses on the crucial aspects of IT infrastructure and technology that support CCHs in their network management, contractual arrangements, and service delivery, including data management, security, hardware and software requirements, interoperability, and shared services. It is tailored to help readers understand the advantages and processes of integrating business functions with IT solutions.
For ease of navigation, the Playbook is divided into two parts with corresponding appendices. Part I of the Playbook provides a holistic understanding of how to leverage IT and shared services to enhance CCH operational efficiency and service delivery. Part II delves into more technical details and addresses regulatory data requirements and contract preparation.
Playbook and Executive Summary