Community action and analysis plan: Guidance and resources for Community Care Hubs to address health-related social needs based on lessons from North Carolina

Addressing unmet health-related social needs (HRSNs) is critical to improving health outcomes and requires well-coordinated systems of health and social care. Community Care Hubs (CCHs) – community-centered backbone organizations that coordinate care between the health and social sectors – play a critical role in developing these coordinated systems of care. CCHs are designed to organize, support, and provide centralized infrastructure for community-based organizations (CBOs) and other service providers that are participating in cross-sectoral partnerships.

CCHs serve a critical role in their communities, but the scope and capacity of CCHs can vary. Given this, there is a need for additional guidance and support to start, scale, and sustain the work of CCHs. The purpose of this Community Action and Analysis Plan is to highlight practical steps that future and current CCHs can take to start, scale, and sustain efforts to address HRSNs. From our research, we identified six major competency areas for CCHs. Below is a high-level summary of the main steps that CCHs can take across the six competencies outlined in this document. This is meant to serve as both a self-assessment tool and a guide through the document’s main points. Within each section, we describe examples of data, resources, and partnerships that can support these efforts, including both foundational skills and advanced steps. Readers can choose to review and focus on topics that are of particular interest and are directed to external sources to read more when such external resources exist.