Functions of a mature community care hub

A community care hub (“CCH” or “hub”) is a community-focused entity that organizes and supports a network of community-based organizations (CBOs) providing services to address health-related social needs (HRSNs). A community care hub 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 community care hub 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. 

Across the healthcare and social care landscapes, there is common recognition of the importance of addressing HRSNs, such as food insecurity, housing instability, and lack of transportation, and the role that social inequality plays in health disparities. To better align social care delivery with healthcare delivery and payment, health plans and systems are partnering with community-based organizations (CBOs) to coordinate and deliver whole-person care that address HRSNs. Recent trends indicate a growing number of health plans contracting with CBOs, particularly through CCHs and the community care networks they organize.

This document is designed to serve as a vision and could inform a roadmap towards a model CCH. The document can be used to guide an assessment of gaps, strengths, and areas for growth. It can also be used to communicate to stakeholders the benefits that hubs bring to a community.