From the beaches of Hawaii to the streets of New York, states across the U.S. are transforming how they care for vulnerable populations. Many have embraced Section 1115 Medicaid Waivers to include health-related social needs (HRSN) services—such as housing, transportation, and nutrition—into Medicaid. These services are not just enhancements; they are critical to improving the well-being of Medicaid beneficiaries who face complex health and social challenges.

 

To provide these non-medical services effectively, a social care delivery network (SCDN) is essential. For years, community-based organizations (CBOs) and nonprofits have been key players in delivering these services, but the growing complexity of today’s healthcare landscape requires a more coordinated, multi-sector approach. Success hinges on collaboration between healthcare providers, social workers, case managers, and community organizations to identify individuals’ needs and connect them with the right services. This demands strong communication, seamless data sharing, and service integration—all while ensuring HIPAA compliance.

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The Emerging Model: Community Care Hubs (CCH)

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Across the country, different models are emerging to support the development of SCDNs. One of the most promising is the Community Care Hub (CCH). These Hubs act as a contractual organization linking social care providers with healthcare organizations to implement sustainable, scalable, and equitable interventions addressing HRSN. Much like managed service organizations (MSOs) that support independent physician associations (IPAs), CCHs serve as the backbone of a coordinated network.

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While these models may differ in structure, two key principles hold true:

1. Quality social care delivery networks require quality social care infrastructure.

2. That infrastructure must meet the holistic needs of network members.

 

What is Social Care Infrastructure?

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Social care infrastructure includes the tools and processes that support every aspect of service delivery: billing, payment operations, referral management, marketing, service quality, training, compliance, and more. It also encompasses cross-sector data exchange—including privacy, security, data collection, and reporting.

 

Technology plays a pivotal role here, just as it does in healthcare. But creating social care infrastructure is not as simple as adapting an existing electronic health record (EHR). Instead, it requires a purpose-built solution for CBOs and social service providers—one that streamlines access to both healthcare and social services while supporting multiple programs with diverse funding sources.

 

The right technology doesn’t just add another platform for data entry; it empowers each organization in the network. By providing a solution that supports each member, a truly effective social care delivery network can be built.

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The Need for a Comprehensive Enterprise Solution

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For example, while CCHs can help negotiate equitable payments to ensure CBO sustainability, these organizations often rely on a complex mix of funding sources—including Medicaid—to maintain operations. What’s needed is a comprehensive enterprise solution that supports healthcare programs, reporting, and funding requirements. Without this, SCDNs will struggle to leverage economies of scale, which limits opportunities for small and diverse CBOs to participate in meaningful healthcare partnerships.

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Overcoming Challenges and Building the Future

 

Despite growing recognition of the value of SCDNs, building an effective social care infrastructure comes with challenges. These include fragmented funding streams, workforce capacity limitations, and the lack of integration between social care and healthcare data systems. Social workers, case managers, and community health workers don’t need multiple platforms—they need a single solution that’s easy to use, streamlines workflow, and supports day-to-day operations.

 

Integrating social care into the healthcare system is essential for addressing health-related social needs and improving population health. By investing in social care infrastructure and fostering collaboration across sectors, we can build more equitable, effective systems of care that reduce disparities and improve health outcomes- while being cost effective.

 

Learn more about IMPOWR:

IMPOWR your social care infrastructure; IMPOWR your Network