Leveraging Health Plan and Community Partnerships to Address Social Determinants of Health

Date: March 08, 2024
Time to read: 10 minutes.

Health care organizations, including health plans, are increasingly focused on the impact that social determinants of health (SDOH) have on the lives of individuals dually eligible for Medicare and Medicaid. As defined by Healthy People 2030, SDOH “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”1 Research suggests that SDOH drive 40 percent of health outcomes.2

The federal government recognizes the value of creating connections between health care, SDOH, and community partnerships. A November 2023 White House report titled The U.S. Playbook to Address Social Determinants of Health identifies the critical role that community-based organizations (CBOs) and other “backbone organizations” play in a well-coordinated health and social care system.3 Moreover, for over a decade, the Administration for Community Living (ACL) has been championing CBOs’ efforts to offer nutrition support, transportation, vaccines, and personal assistance needs. Specifically, ACL collaborates with area agencies on aging, centers for independent living, aging and disability resource centers, and other organizations that provide access to long-term services and supports for people with disabilities and older adults.4 ACL’s recent work with CBOs focuses on increasing effectiveness, efficiency, and sustainability of services to improve SDOH by addressing health-related social needs (HRSNs). For instance, ACL supports community care hubs—community-focused entities bolstering a network of CBOs that provide HRSNs—through national learning communities and a Center of Excellence to Align Health and Social Care.5,6 These efforts support CBOs as they grow their business acumen to develop sustainable operating infrastructure with health care partners, including health plans.7

Key SDOH factors, including but not limited to food and housing insecurity, low health literacy, and poverty, disproportionately affect dually eligible individuals when compared with their Medicare-only counterparts.8 Individuals lacking stable housing or experiencing hunger, for example, may prioritize those needs above their health issues.9,10 Health plans that consider the role of SDOH in their dually eligible members’ lives can help provide meaningful person-centered care coordination. Placing SDOH front and center when leveraging coordination strategies (e.g., providing referrals to or developing partnerships with neighborhood groups that address social needs) can also give plans an opportunity to reduce socioeconomic health care disparities.11,12

The following examples draw on the Resources for Integrated (RIC) Brief on Key Considerations For Health Plans: Partnering With Community-Based Organizations To Address Social Determinants Of Health, insights from health plan participants in the 2022 RIC Integrated Care Community of Practice (ICCoP) that focused on care coordination for dually eligible individuals,13 and the SCAN Foundation.

Leveraging Partnerships to Address Social Determinants of Health

As the RIC Brief discusses, CBOs are natural partners for health plans. Such partnerships enable plans to leverage a CBO’s established relationships and existing trust among community members. They also offer plans access to robust local networks within a plan’s service area or areas. In addition, many CBOs have extensive experience providing services and supports within their community—often within individuals’ homes. In short, such partnerships provide opportunities for health plans to leverage CBO infrastructure to address member SDOH-related challenges, such as increasing caregiver supports, combatting social isolation, offering behavioral health care services, providing transportation assistance, and supporting access to meals.

ICCoP participants offered several potential avenues for health plan and CBO collaborations that could support care coordination and address SDOH. For example:

  • Tailored collaboration to meet member needs. Integrating community-based partners in the care plan development process can help plans meet members’ social needs by leveraging available community resources to support health plan efforts around member health literacy and provider cultural competence.14 For example, partnering with organizations that cater to the LGBTQ+ community may help a plan build trust with otherwise hard-to-reach and at-risk dually eligible populations. An additional partnership for health plans serving members experiencing homelessness could be with community centers that grant members access to facilities to safely use showers and bathrooms.
  • Increasing at-home support. Partnerships with CBOs that deploy community-based nurses to a member’s home may enhance the level of at-home support plans can offer to their homebound members, preventing avoidable emergency department visits or admissions. These partnerships can provide a range of services to members who wish to maintain independence but who have greater health needs.
  • Implementing post-discharge supports. Health plans can collaborate with health systems and CBOs to receive timely notification of member hospitalizations or emergency department visits to facilitate post-discharge supports (e.g., nursing, medical equipment, transportation, meal access), which can reduce unnecessary readmissions.15
  • Engaging leadership in community partnership. As RIC shared in another post, MyChoice Wisconsin encourages its leadership to develop relationships with community partners and local organizations to support care coordination and help resolve emergent issues. As a result, MyChoice Wisconsin leadership attends and participates in local coalition groups, such as a local crisis stabilization task force, a dementia coalition, and adult protective services.16

Aligned with the suggestions from ICCoP participants, the RIC Brief highlighted how CBOs can offer additional expertise and resources to support health plan activities. For example, the Health Plan of San Mateo (HPSM) leverages partnerships to reduce costs through its Community Care Settings Program (CCSP). HPSM partners with two CBOs experienced in integration and community living to support care transition management.17 These CBOs provide expertise and logistical support to help find housing for HPSM members, settle disputes with landlords, and modify homes to increase accessibility. The partnerships also increase HPSM’s care management capacity. HPSM added a third CBO partnership to establish social connections and program access for members who were experiencing social isolation following a transition to at-home care. Among individuals who participated in CCSP for six months, HPSM reduced per-member, per-month costs by an average of 35 percent (cost data compared 2014 to 2018) while simultaneously achieving high levels of member satisfaction and retaining 98 percent of program participants in the community.18,19

Considerations for Establishing Partnerships

Prior to establishing partnerships with CBOs to address SDOH-related concerns, plans should consider several steps. The SCAN Foundation recommends that health plans develop a request for information (RFI) and a request for proposals (RFP) when seeking out CBO partnerships.20 This process helps the plan establish expectations and clarify reporting, oversight, and access requirements within a potential partnership. To support RFI and RFP development, the plan should first complete an organizational readiness assessment and articulate answers to key questions, including:21

  • What are the SDOH-related issues the plan seeks to target and who are its potential partners? Health plans should regularly assess their population to understand the core SDOH issues that are faced by their members. Identification of specific SDOH will streamline the work to identify partners that could potentially help tackle the challenges faced in the community.
  • How will internal processes change? Plans may want to consider how workflow, stakeholders, and staff training needs may change after establishing partnerships. For example, as RIC posted, one plan—MyChoice Wisconsin—partnered with health systems providing care for their members and together established standing meetings for the health systems’ directors of social work and MyChoice Wisconsin’s care coordination team to address member inquiries. The partners found the sessions so successful that they expanded the meeting attendee list to include additional key personnel (e.g., directors of emergency department care coordination, inpatient care coordination, discharge).
  • How will the plan define success? Developing key performance indicators and tracking utilization, claims, and quality will help both the plan and the partnering organization monitor performance and gauge effects of the intervention. To support such efforts, partners should discuss data sharing approaches at the outset.
  • What is the business case for partnership? While the goal of the partnership may be to reduce readmission rates, improve outcomes and experience of care, or decrease SDOH-related health care disparities, reducing plan costs will help the business case and support long-term sustainability. Plans may wish to start small by establishing pilot programs with potential partners to gauge feasibility. They may also wish to quantify anticipated partnership outcomes for both the plan and the CBO. Some ICCoP participants noted difficulties in getting long-term buy-in from CBOs and found that the Commonwealth Fund’s Return on Investment calculator helped both potential partners and plan leadership craft mutually beneficial agreements.22
  • How will the plan track any savings the intervention generates? Tracking savings is a must for any partnership—which may have costs of its own. Understanding all the ways a partnership imparts savings for the health plan is key to maintaining buy-in over time.

By working together, health plans and partners – especially CBOs – can provide targeted support to address care coordination and SDOH and, ultimately, improve dually eligible individuals’ experiences.

For additional information, please see the following resources:

1Office of Disease Prevention and Health Promotion. (n.d). Social Determinants of Health. Retrieved from https://health.gov/healthypeople/priority-areas/social-determinants-health.

2Catlin, B. B., & Willems Van Dijk, J. T. (2020). Ten-Year Reflections on the County Health Rankings & Roadmaps on the County Health Rankings & Roadmaps. University of Wisconsin Population Health Institute. Retrieved from https://www.countyhealthrankings.org/sites/default/files/media/document/CHRR10_year_reflections_report.pdf.

3The White House Domestic Policy Council. (2023). The U.S. Playbook to Address Social Determinants of Health. Retrieved from https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf.

4Administration for Community Living. (2023). Advancing Partnerships to Align Health Care and Human Services. Retrieved from https://acl.gov/programs/strengthening-aging-and-disability-networks/improving-business-practices.   

5Chappel, A., Cronin, K., Kulinski, K., Whitman, A., DeLew, N., Hacker, K., Bierman, A.…Sommers, B. (2022).  Improving Health And Well-Being Through Community Care Hubs. Health Affairs Forefront. Retrieved from https://www.healthaffairs.org/content/forefront/improving-health-and-well-being-through-community-care-hubs?utm_medium=email&utm_source=hat&utm_campaign=forefront&vgo_ee=rzCw6XNh1EI14JZF9YsXjRs0qiNrypLKV2rY8rE1sLg%3D.

6The Office of the Assistant Secretary for Planning and Evaluation & the Administration for Community Living. (2023). Community Care Hubs: A Promising Model for Health and Social Care Coordination. Retrieved from https://aspe.hhs.gov/sites/default/files/documents/5b8cba1351a99e904589f67648c5832f/health-social-care-coordination.pdf.

7Administration for Community Living. (n.d.). CCH National Learning Community. Retrieved from https://www.ta-community.com/category/cch-national-learning-community.

8Sorbero, M., Kranz, A., Bouskill, K., Ross, R., Palimaru, A., & Meyer, A. (2018). Addressing Social Determinants of Health Needs of Dually Enrolled Beneficiaries in Medicare Advantage Plans. U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/private/pdf/259896/MAStudy_Phase2_RR2634-final.pdf.

9Better Medicare Alliance Center for Innovation in Medicare Advantage. (2021). Innovative Approaches to Addressing Social Determinants of Health for Medicare Advantage Beneficiaries. Retrieved from https://bettermedicarealliance.org/wp-content/uploads/2021/08/Innovative-Approaches-to-Addressing-SDOH-for-MA-Beneficiaries-FINAL.pdf.

10Resources for Integrated Care. (2023). Engaging Hard-To-Reach Members – Vulnerable Populations. Retrieved from https://www.resourcesforintegratedcare.com/engaging-hard-to-reach-members-vulnerable-populations/.  

11Centers for Medicare & Medicaid Services Federal Coordinated Health Care Office. (2023). FY 2022 Medicare-Medicaid Coordination Office Report to Congress. Retrieved from https://www.cms.gov/files/document/mmco-report-congress.pdf-0/.  

12Sorbero, Melony. (2018).

13Note that the partnerships described in this post focus on CBOs, including non-profits, area agencies on aging, centers for independent living, and aging and disability resource centers, but health plans can partner with a number of organizations, including other health plans or state agencies (e.g., health departments).

14Resources for Integrated Care. (2023). Community Care Plans – Spotlight On My Choice Wisconsin. Retrieved from https://www.resourcesforintegratedcare.com/ric-care-coordination-blog-community-care-plans-spotlight-on-my-choice-wisconsin/.



17Resources for Integrated Care. (2021). Key Considerations For Health Plans: Partnering With Community-Based Organizations To Address Social Determinants Of Health. Retrieved from https://www.resourcesforintegratedcare.com/health_plans_community_based_organizations_address_sdoh/.


19Center for Health Care Strategies. (2019). Facilitating Community Transitions for Dually Eligible Beneficiaries. Retrieved from https://www.chcs.org/resource/facilitating-community-transitions-for-dually-eligible-beneficiaries/.

20The SCAN Foundation. (2019). Blueprint for Health Plans: Integration of CBOs to Provide Social Services and Supports (Full Report). Retrieved from https://www.thescanfoundation.org/publications/blueprint-for-health-plans-integration-of-cbos-to-provide-social-services-and-supports-full-report/.

21Resources for Integrated Care. (2021).

22The Commonwealth Fund & The SCAN Foundation. (n.d.). Welcome to the Return on Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health. Retrieved from https://www.commonwealthfund.org/roi-calculator.