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Where Data, Value-Based Care, and Community Align

Identifying needs, improving outcomes, and promoting healthy behaviors

ADVANCING QUALITY METRICS THROUGH COMMUNITY INTEGRATION 

Community Projects

Partnering with communities to design, manage, and evaluate locally driven initiatives.

 

Our work includes community-led planning, cross-sector partnerships, grant-funded and pilot projects, implementation and reporting, and evaluation - supporting sustainable, community-defined solutions.

Health Education

Delivering evidence‑informed, prevention‑focused programs that improve population health.

 

The partner network provides health promotion, chronic disease prevention, and partner training education in alignment with state and federal priorities - supporting healthier behaviors and better access to prevention resources.

Community Health

Bridging health care and community services to reduce

silos and access barriers.

 

We provide and support screening and referral workflows, service connections, navigation and follow‑up, and partnerships across health and social care - improving access to care, continuity, and unmet social needs.

CONNECTING HEALTHCARE INVESTMENT TO COMMUNITY IMPACT

Contracting with a Community Care Hub offers healthcare organizations and health plans a scalable, accountable way to address whole-person health while improving quality and controlling costs. By serving as a centralized infrastructure that coordinates trusted community-based organizations (CBOs), a CCH streamlines referrals, standardizes data collection, ensures program fidelity, and reduces administrative burden. Instead of managing multiple small contracts, healthcare entities work with one accountable partner that aligns community services with clinical goals and value-based payment strategies. For healthcare systems operating under capitated or other value-based payment models, a CCH helps manage total cost of care by addressing social drivers of health, strengthening care transitions, and reducing avoidable utilization. Through coordinated community health worker (CHW) initiatives—whether delivered under flexible fee-for-service arrangements or embedded in alternative payment models—patients receive hands-on support with medication adherence, follow-up appointments, nutrition access, housing stability, and chronic disease self-management. Evidence-based health promotion programs further enhance patient activation and self-efficacy, supporting better outcomes for individuals living with diabetes, heart disease, chronic pain, fall risk, and other complex conditions. For insurers and health plans, partnering with a CCH creates a reliable mechanism to deploy community-based interventions at scale while maintaining quality oversight and measurable outcomes. A hub can support complex case management, high-risk member outreach, and post-discharge follow-up to reduce readmissions and emergency department utilization. With centralized reporting and standardized metrics, plans gain actionable data that demonstrate return on investment, improved HEDIS and Star ratings performance, and enhanced member experience. Ultimately, contracting with a Community Care Hub aligns clinical care, community services, and payment reform. By integrating evidence-based programs, coordinated care transitions, and community health worker support into a cohesive system, healthcare organizations and insurers can improve member satisfaction, strengthen provider relationships, and achieve sustainable cost reductions—while advancing equitable access to prevention and wellness services across the communities they serve.

Integrating clinical care with accountable community infrastructure turns population health strategy into measurable results.

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Contact us to explore contracting opportunities that reduce cost of care, strengthen care transitions, and improve member and patient satisfaction.

 

Schedule a Discovery Session

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