Skip to main content

    Free executive playbook · 2026 edition

    The Community Care Hub Playbook

    Funding, capacity, outcomes and technology strategy for the leaders of community care hubs and CBO networks doing HRSN/SDoH care coordination. Action-first, sourced, and vendor-neutral.

    Read the one-page summary See all 12 chapters

    Research current as of November 2026. 76 cited sources.

    Hub leaders around a regional map planning their partner network

    Waiver ceilings are permission, not revenue. Plan as if every dollar has to be re-earned.

    • $23.8B

      HRSN authority in 18 states[1]

    • 70+

      community care hubs on USAging's national map[13]

    • 52%

      of nonprofits hold ≤3 months of cash[5]

    • 47%

      of CBOs now contract with health care[9]

    Chapter 01 · For the board packet

    Five issues on every hub executive's desk — and what to do about each.

    Hubs sit between health care payers and community organizations. That position is valuable and fragile: you carry contract, cash, workforce and evidence risk for an entire network.

    1. Funding is less certain

      $23.8B

      HRSN spending authority across 18 states — authority, not cash in hand[1]

      CMS rescinded its HRSN guidance in March 2025, and federal Medicaid reductions are projected at about $911B over a decade. Existing waivers continue, but renewals will face harder questions.

      Map every dollar by source and expiry. Treat waiver ceilings as permission, not revenue.

    2. Cash runway is thin

      52%

      of nonprofits have three months of cash or less[5]

      Hubs often pay partner CBOs before plans pay the hub. Every week of claim delay is borrowed from reserves.

      Measure days from service to cash for every contract, and price the lag into rates.

    3. Demand is outrunning capacity

      54%

      of nonprofits expect they won't meet demand this year[5]

      85% expect demand to rise. Referrals sent to a partner with no open slot become waitlists, not services.

      Track open capacity by partner and program weekly; route referrals to where slots exist.

    4. The workforce is stretched

      74.6%

      of nonprofits report staff vacancies[7]

      Community health workers who feel unsupported are about twice as likely to intend to leave (50% vs 24%).

      Cut double data entry, fund supervision, and benchmark pay before the next contract cycle.

    5. Proof now decides payment

      70%

      of contracting CBOs are paid on clients served or service units[9]

      Reporting is no longer an afterthought — it is the invoice. Weak data means lost revenue and weak renewals.

      Agree eight shared metrics across the network and report them monthly to your board and payers.

    Figures: GAO (2025)[1], CMS (2025)[2], KFF (2025)[3], Nonprofit Finance Fund (2025)[5], National Council of Nonprofits (2023)[7], AJPH (2024)[8], USAging ADBI (2024)[9].

    The bottom line

    The hubs that last will be the ones that can prove value, price it fully and run the network on one set of data.

    Funding programs will keep changing. Evidence, financial discipline and a workforce that isn't buried in duplicate paperwork travel from one program to the next.

    Seven moves for the next 12 months

    1. Map your position in the payment chain: who contracts, authorizes, bills, pays, owns the data and carries the risk.
    2. Separate one-time infrastructure money from recurring operating revenue in every budget.
    3. Price the full cost of each contract, including administration and payment lag.
    4. Adopt one network-wide evidence ladder, from reach to resolved need to cost.
    5. Give partner CBOs one place to work, so no one types the same record twice.
    6. Protect the workforce with supervision, training and pay benchmarks.
    7. Prepare 2027–2029 waiver renewals now, with evidence ready before it's requested.

    Chapter 02 · Know your model

    The four hub models — and which rules you play by.

    “Hub” means different things in different states. Your model decides who writes your rules, who pays you and what your technology must do. Tap a model to compare.

    CCH · The national contracting and operations model

    Community Care Hub

    Who leads
    A trusted CBO (often an Area Agency on Aging or Center for Independent Living) or a separate organization the network creates.
    How it's funded
    Health plan and health system contracts, Medicaid and Medicare programs, public grants.

    What it does

    • Single point of contracting with health care
    • Payment operations for the network
    • Referral management
    • Service fidelity and compliance
    • Technology and information security
    • Data collection and reporting

    Examples: Mass Home Care, Illinois Pathways to Health, Partners in Care Foundation, Iowa Community HUB, Western New York Integrated Care Collaborative.

    27

    average member CBOs per hub network (median 21)[9]

    Executive watch-out

    Mean contracts per network were 5.9 but the median was 2 — most hubs are earlier in their journey than the headline averages suggest.

    Hub models compared
    At a glanceCCHACHSCNRNL
    Who sets the rulesThe hub and its contractsRegional governance boardState Medicaid agencyState program office
    Main payer linkPlans, systems, Medicare/MedicaidState demonstrationMedicaid managed careMedicaid plans via state pilot
    GeographyState, region or multi-stateDefined regionState-assigned regionState-assigned region
    Biggest tech needContracting, billing, CBO paymentShared data and measurementScreening-to-claim complianceInvoicing and network oversight

    Related models you'll meet

    • AAA- and disability-led hubs

      86% of surveyed hub networks include Area Agencies on Aging.[9]

    • Massachusetts Flexible Services

      ACO-purchased housing and nutrition supports; $10M to 37 CBOs in January 2025.[28][29]

    • CMS AHC bridge organizations

      28 bridge organizations screened 1.1M+ people; CMS reports $200M+ net savings.[33][34]

    • CalAIM ECM and Community Supports

      372,000+ ECM members and 429,000+ Community Supports members via plan contracts.[27]

    Models overlap: an ACH can operate a community care hub, and an Area Agency on Aging can host one. Counts come from surveys and state rosters, not a complete national registry.

    Chapter 03 · Use cases

    State playbooks: what's working, what broke.

    Eight states show the range — from New York's state-designated networks to North Carolina's proven-then-paused pilots. Pick a state.

    NYHER 1115 waiver

    New York

    Model: Social Care Networks

    • 9

      regional SCN leads[20]

    • $500M

      over three years[20]

    What executives should take from it: Platform, data exchange and network roles are deliberately separate: the SCN runs the network, the regional HIE moves data, and a referral platform carries the workflow.

    Pennsylvania and Illinois figures are federal spending ceilings for HRSN services; actual awards and spending are lower and depend on state implementation.

    Chapter 04 · Market research

    The five business pressures, in numbers.

    Limited resources, the need for more funding, cost pressure and a stretched workforce — each with a move you can make this quarter.

    1. Funding volatility and policy shifts

      Waiver authority, state budgets and federal guidance all moved in 2025. Ceilings approved by CMS are not appropriations; NC's suspension shows how fast funded programs can stop.

      Build a three-scenario budget (base, cut, growth) and a renewal evidence file for each funder.

      84%

      of government-funded nonprofits expect cuts[5]

    2. Contracting costs nearly what it earns

      Health care contracts bring credentialing, compliance, claims and reporting overhead that grants rarely do. Without full-cost pricing, growth can lose money.

      Calculate contribution margin per contract, including administration, before renewing or expanding.

      26%

      of revenue from health care contracts — and 26% of expenses spent delivering them[9]

    3. Thin cash and slow payment

      Hubs commonly front payments to partner CBOs. Denials and rework stretch the gap between service and cash.

      Track days-to-cash and first-pass claim acceptance as board-level metrics.

      18%

      of nonprofits have one month of cash or less[5]

    4. Demand outpacing capacity

      More referrals without more capacity produces waitlists. 28% of nonprofits already report longer waitlists due to vacancies.

      Publish open capacity by partner and program; use it to steer referrals and to justify rate requests.

      85%

      of nonprofits expect demand to rise[5]

    5. Workforce shortages and burnout

      Care coordinators carry heavy caseloads and duplicate documentation across systems. Organizational support is the strongest retention lever in the research.

      Measure documentation time per encounter and set a target to cut it.

      51.7%

      report more vacancies than before the pandemic[7]

    A care coordinator working late, supported by a colleague

    Burnout is an operations problem before it's an HR problem.

    Community health workers who felt unsupported by their organization were about twice as likely to say they intended to leave — 50% versus 24%.[8] The levers executives control: caseload limits, real supervision, fewer systems and less duplicate documentation.

    Intent to leave is not the same as measured turnover.

    Chapter 05 · Evidence

    Outcome reporting is how funding gets renewed.

    Reporting now drives payment directly — and it drives the board's decisions about where to grow, which partners to fund and which contracts to keep.

    • 70%

      of contracting CBOs are paid on clients served or service units[9]

    • 46%

      have contract measures for data submission and reporting[9]

    • 37%

      of AHC-screened people had at least one core need; 18% qualified for navigation[33]

    • $200M+

      net savings reported by CMS for the AHC model[34]

    The evidence ladder

    Each rung answers a different funder's question. Most networks report the bottom two; renewals are won on the top three.

    1. Reach

      People screened, eligible and enrolled · Asked by: Every funder

    2. Connection

      Referrals accepted, time to first service · Asked by: Health plans, state

    3. Delivery

      Services and units completed as authorized · Asked by: Payers (this is the invoice)

    4. Resolution

      Needs resolved at reassessment · Asked by: Plans, foundations

    5. Experience & equity

      Satisfaction and results by population · Asked by: Board, state, community

    6. Workforce

      Caseload, vacancies, documentation time · Asked by: Board, leadership

    7. Cost & utilization

      ED, inpatient and total cost vs. a comparison group · Asked by: Plans, state, CMS

    The eight-metric executive scorecard

    • Referral acceptance rate

      Shows whether the network has capacity and fit.

    • Median days referral → first service

      The first number plans ask about.

    • Needs resolved at reassessment

      Converts activity into outcomes.

    • First-pass claim acceptance

      Predicts cash flow.

    • Days from service to cash

      Your real working-capital need.

    • Open capacity by partner

      Steers referrals and rate negotiations.

    • Staff vacancies and caseload

      Early warning for burnout and service gaps.

    • Cost per resolved need

      The basis for sustainable pricing.

    Why rigor protects funding

    In Camden's randomized trial of 800 patients, 180-day readmissions were 62.3% with the program and 61.7% without it. A simple before-and-after look would have shown a misleading 38-point drop. Payers increasingly know the difference — claims built on comparison groups survive scrutiny; before-and-after claims don't.[37][38]

    The same trial found a significant increase in SNAP enrollment — a reminder to measure social outcomes, not only hospital use.

    Chapter 06 · The technology gap

    Why the technology doesn't fit together.

    Most hubs run on a referral platform, a billing service, grant spreadsheets, state portals and email. Each works; together they make staff the integration layer.

    • Referral platform
    • Case notes system
    • Billing service
    • Grant spreadsheets
    • State portals
    • Payer portals
    • Shared drives
    • Email and phone

    One record per person, connected to the state's exchanges

    Document once. Claims, grant reports, partner payments and board dashboards come from the same data.

    • Several systems per agency

      A national survey of Area Agencies on Aging found agencies used, on average, two state systems, two administrative systems and two client-service systems — many unable to talk to each other. (2015 data; no newer national count exists.)[41]

    • Multiple data entry

      Washington's statewide assessment named multiple data entry as a core pain point for community care coordination, with overlapping platforms across regions.[42]

    • Different data, different designs

      ONC attributes coordination failures to nonuniform data collection, varied system designs and uneven exchange capacity — and says governance and financing matter as much as software.[43]

    • Referral tools aren't operating systems

      Most referral platforms move a referral well. Few also run case notes, claims, CBO payment, grants and executive reporting — so hubs bolt on spreadsheets.[44]

    Chapter 07 · What to buy

    The 14-part technology stack a hub needs.

    Use this as an acceptance checklist. For each area: what it must do, the question to ask any vendor, and — for transparency — where CH360 stands today.

    • CH360: Available
    • CH360: Partial
    • CH360: In development
    • CH360: Roadmap

    1. Member management & eligibility

      Must do: One record per person and household; payer enrollment vs. service eligibility; authorization dates.[22]

      Ask vendors: Show how you match duplicates and track eligibility history.

      CH360: AvailableClient records with intake, demographics and multi-site hub views.

    2. Standardized screening

      Must do: Keep the instrument, version, answers, language and reassessment dates.[45][46]

      Ask vendors: Demonstrate AHC and PRAPARE specifically, not a custom form.

      CH360: AvailableStandardized HRSN screening with structured results.

    3. Closed-loop referrals & resource directory

      Must do: Acceptance, rejection, waitlist, completion and reason codes, with client permission.[52][43]

      Ask vendors: Show status returning from a partner on a different platform.

      CH360: PartialReferrals across hub partners; connects to state CIEs rather than replacing them.

    4. Case management & case notes

      Must do: Longitudinal record, assigned team, signed time-stamped notes, escalation.[64]

      Ask vendors: Walk through a 90-day case, not just a referral inbox.

      CH360: AvailableCase notes with AI-drafted notes for staff review.

    5. Care plans & authorizations

      Must do: Goals, tasks, authorized units and expiry alerts.

      Ask vendors: Show what happens when an authorization runs out.

      CH360: PartialService plans; authorization tracking runs through RCM.

    6. Network & contract management

      Must do: CBO roster, capacity, contracts, rate schedules, quality oversight.[49]

      Ask vendors: Show a rate change flowing to claims and partner payments.

      CH360: PartialHub-and-spoke partner organizations; contract and rate management in development.

    7. Workforce & credentials

      Must do: Roles, caseload, CHW/CCHW credential validity, training, supervision.

      Ask vendors: Show credential expiry blocking a claim.

      CH360: AvailableCHW/THW credential tracking with renewal alerts and role-based seats.

    8. HRSN billing & claims

      Must do: Payer-specific codes, modifiers, units, NPI; 837P, acknowledgments, claim status.[76]

      Ask vendors: Submit a test claim to one of your actual plans.

      CH360: AvailableHRSN code and modifier validation; claims via Office Ally's payer network.

    9. Revenue cycle management

      Must do: Eligibility checks, scrubbing, denials, appeals, remittance posting, reconciliation.

      Ask vendors: Who works denials — your staff, the vendor or a partner?

      CH360: AvailableRevenue Cycle Management: eligibility, claim scrubbing, denials, remittance posting and reconciliation.

    10. Payments to partner CBOs

      Must do: Calculate, approve and disburse partner payments; reconcile to remittances.[60]

      Ask vendors: Show a hub paying five CBOs from one remittance.

      CH360: AvailableCare Hub settlements in RCM: split each payment among partner CBOs with approved hub fees, statements and disputes.

    11. Reporting, outcomes & executive analytics

      Must do: Separate reach, completion, timeliness and outcomes; stratify; keep denominators.[43]

      Ask vendors: Show a funder report built without a spreadsheet.

      CH360: PartialAutomated funder reports today; executive capacity analytics shown as a demo.

    12. Grant management

      Must do: Tie services and costs to funding sources; budgets, deliverables, renewals.[66]

      Ask vendors: Show one service allocated across two grants.

      CH360: AvailableAwards, budget vs. actuals, deliverables and renewal readiness.

    13. Member portal

      Must do: Accessible, multilingual self-screening, status, documents and consent.[69]

      Ask vendors: Is it an authenticated portal or a public search page?

      CH360: AvailableMember Portal: authenticated intake, documents, consent and request status.

    14. Interoperability, consent & security

      Must do: FHIR/Gravity, consent and revocation, audit, export; HIPAA and 42 CFR Part 2.[47][48]

      Ask vendors: Name the FHIR version and Gravity profiles you support today.

      CH360: PartialHIPAA-ready app with BAA, MFA, audit trail and APIs; standards mapping scoped per state.

    Coding caution: Medicare Community Health Integration codes and Medicaid HRSN waiver services are different purchasing specifications. Require your contracted payer's current codes, supervision, consent and documentation rules.

    Chapter 08 · Infrastructure

    CIEs and HIEs: where each fits.

    Three layers, three jobs. Hubs get into trouble when they expect one layer to do another's work.

    1. Community Information Exchange (CIE)

      A community-governed network for sharing social-care information and referrals across health, human and social services. It includes governance, legal agreements and community ownership — not just a directory you buy.

      In practice: 211 San Diego CIE; NCCARE360; Washington's regional CIE planning.[50][57][42]

    2. Your hub's operating system

      Where contracts, cases, claims, CBO payments, grants and outcome reporting actually happen. It should plug into the CIE and HIE, not compete with them.

      In practice: New York shows the pattern: SCN runs the network, regional HIEs (QEs) move data, a platform carries the workflow.[22]

    3. Health Information Exchange (HIE)

      Infrastructure that moves clinical data among providers — admissions alerts, records, APIs. For a hub, it supplies clinical context; it does not run CBO contracts, payments or capacity.

      In practice: CRISP (MD) adds social-needs referrals; Manifest MedEx (CA) is building a statewide social HIE with NinePatch; IHIE (IN) is a statewide health data utility.[51][52][54][55]

    About TEFCA: TEFCA creates national exchange pathways between networks. On its own it does not supply social-service directories, closed-loop referrals or HRSN reimbursement.[56]

    Agree identity matching, permissions, a minimum dataset and referral-status meanings across all three layers before you sign any contract.

    Chapter 09 · Objective comparison

    The vendor landscape, without the sales pitch.

    What each vendor's public documentation supports, function by function. It's a map for your own diligence, not a ranking — and CH360 is held to the same rules.

    • Strong
    • Partial
    • Not documented
    • Roadmap

    • Unite Us[58][59][60][57]

      incl. NowPow (acquired 2021)

      Referrals / CIE
      Strong
      Case management
      Partial
      HRSN billing
      Strong
      RCM
      Strong
      CBO payments
      Strong
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Partial

    • findhelp[61][62][63]

      platform + waiver operations

      Referrals / CIE
      Strong
      Case management
      Partial
      HRSN billing
      Strong
      RCM
      Partial
      CBO payments
      Strong
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Partial
      Network & contracts
      Partial

    • Activate Care[64][65]

      CareLink + billing partner

      Referrals / CIE
      Strong
      Case management
      Strong
      HRSN billing
      Strong
      RCM
      Strong
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Partial

    • WellSky[66][67]

      Aging & Disability, Community Services, Social Care Coordination (former Healthify)

      Referrals / CIE
      Strong
      Case management
      Strong
      HRSN billing
      Not documented
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Partial
      Member portal
      Not documented
      Network & contracts
      Partial

    • Bonterra[68]

      Apricot, Penelope, ETO

      Referrals / CIE
      Partial
      Case management
      Strong
      HRSN billing
      Partial
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Strong
      Network & contracts
      Not documented

    • Salesforce[69]

      Nonprofit Cloud, Health Cloud

      Referrals / CIE
      Partial
      Case management
      Strong
      HRSN billing
      Not documented
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Strong
      Member portal
      Strong
      Network & contracts
      Partial

    • Epic Compass Rose[71]

      EHR-embedded social care

      Referrals / CIE
      Partial
      Case management
      Strong
      HRSN billing
      Not documented
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Partial

    • Socially Determined[70]

      SocialScape analytics

      Referrals / CIE
      Not documented
      Case management
      Not documented
      HRSN billing
      Not documented
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Strong
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Not documented

    • Office Ally[76]

      EDI clearinghouse

      Referrals / CIE
      Not documented
      Case management
      Not documented
      HRSN billing
      Partial
      RCM
      Partial
      CBO payments
      Not documented
      Outcomes reporting
      Not documented
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Not documented

    • Pieces Connect[72]

      historical evidence only

      Referrals / CIE
      Partial
      Case management
      Partial
      HRSN billing
      Not documented
      RCM
      Not documented
      CBO payments
      Not documented
      Outcomes reporting
      Partial
      Grant management
      Not documented
      Member portal
      Not documented
      Network & contracts
      Not documented

    • Pear Suite[73][74][75]

      CHW care navigation, billing + provider network

      Referrals / CIE
      Strong
      Case management
      Strong
      HRSN billing
      Strong
      RCM
      Partial
      CBO payments
      Partial
      Outcomes reporting
      Strong
      Grant management
      Partial
      Member portal
      Not documented
      Network & contracts
      Strong

    • CH360

      self-assessment, labelled

      Referrals / CIE
      Partial
      Case management
      Strong
      HRSN billing
      Strong
      RCM
      Strong
      CBO payments
      Strong
      Outcomes reporting
      Strong
      Grant management
      Strong
      Member portal
      Strong
      Network & contracts
      Partial
    • Ratings reflect public documentation reviewed in 2026, not tested performance. “Not documented” means we couldn't verify it — ask, don't assume it's missing.
    • Signify Health and CenterWell (CVS) and integrated-eligibility platforms such as Cúram deliver services or government eligibility systems, not purchasable hub software, so they aren't rated.
    • Product families are often separately licensed. Confirm which capabilities are in the license you're quoted.
    • The CH360 row is our own assessment. We've rated it by the same rules and marked unfinished work as roadmap.

    Core strength of each, in a sentence

    • Unite Us · incl. NowPow (acquired 2021)

      Cross-sector referral networks with waiver reimbursement; powers NCCARE360 across all 100 NC counties.

    • findhelp · platform + waiver operations

      Resource discovery and closed-loop referrals; generates 837 files; live with several NY SCNs.

    • Activate Care · CareLink + billing partner

      Longitudinal community case management; RCM delivered with a named billing partner.

    • WellSky · Aging & Disability, Community Services, Social Care Coordination (former Healthify)

      Strong aging-network and funder reporting heritage; links services to grants. Products may be separately licensed.

    • Bonterra · Apricot, Penelope, ETO

      Configurable nonprofit case management and outcomes; client portal via Penelope ClientConnect.

    • Salesforce · Nonprofit Cloud, Health Cloud

      Highly configurable platform; grants and portal need optional modules and implementation partners.

    • Epic Compass Rose · EHR-embedded social care

      Strong inside health systems on Epic; not designed as CBO reimbursement infrastructure.

    • Socially Determined · SocialScape analytics

      Social-risk analytics layer — complements, rather than replaces, workflow systems.

    • Office Ally · EDI clearinghouse

      Claims rails (eligibility, 837, status, 835) used by many vendors — including CH360.

    • Pieces Connect · historical evidence only

      Formerly Pieces Iris; current availability not publicly documented — verify before shortlisting.

    • Pear Suite · CHW care navigation, billing + provider network

      Built for community health worker programs: care plans, closed-loop referrals, claims through an integrated clearinghouse, and a provider network CBOs can bill through. Supports regional hubs managing sub-organizations; 300+ organizations onboarded.

    • CH360 · self-assessment, labelled

      Newer, fast-growing, disruptive entrant with the latest AI embedded — including free AI funding tools — plus affordable, high-quality AI features that keep costs low. One system for case notes, HRSN billing, revenue cycle management with partner-CBO settlements, member portal, grants and reporting.

    The one demo to require

    Select against your workflow, not the label “SDoH platform.”

    Ask every finalist to run this end to end, and to say which steps are native, separately licensed, partner-run or manual.

    1. 1. Eligible member
    2. 2. Screening
    3. 3. Consent
    4. 4. Authorized referral
    5. 5. CBO accepts
    6. 6. Service note & plan update
    7. 7. Payer-valid claim
    8. 8. Denial handling
    9. 9. Remittance
    10. 10. CBO payment
    11. 11. Outcome & funder report

    Chapter 10 · Strategy

    Business strategy and technology strategy are one plan.

    Six business decisions and six technology principles that keep a hub durable when programs change.

    Business strategy

    • Position

      Decide where you sit in the payment chain — and which risk you're willing to carry.

    • Portfolio

      Set a ceiling on reliance on any one funder; blend contracts, grants and philanthropy.

    • Pricing

      Full-cost rates that include administration, technology and payment lag.

    • People

      A workforce plan with supervision ratios, credential pipelines and pay benchmarks.

    • Proof

      A shared evidence ladder and an evaluation partner before you need one.

    • Partnership

      Governance that gives small, trusted CBOs a real voice and fair economics.

    Technology strategy

    • One place to work

      Partner CBO staff should document once; everything else is derived.

    • Connect, don't replace

      Plug into the state CIE and HIE; don't build parallel ones.

    • Standards first

      Require Gravity/FHIR mapping and full data export in the contract.

    • Own your data

      You — not the vendor — should hold the longitudinal record and the exit plan.

    • Security by design

      BAAs, role-based access, consent and Part 2 controls reviewed by counsel.

    • Total cost, not license cost

      Count implementation, integrations, billing services and staff time.

    Chapter 11 · Action plan

    A 12-month roadmap and the RFP questions that matter.

    1. Days 0–90

      Assess

      • Map contracts, funding sources and expiry dates
      • Inventory every system and spreadsheet partners use
      • Baseline the eight scorecard metrics
      • Name an executive sponsor and data owner

    2. Days 90–180

      Design & select

      • Agree the network operating model and governance
      • Write the end-to-end demo script
      • Run a structured vendor selection against it
      • Set full-cost rates for the next contract cycle

    3. Days 180–365

      Implement & prove

      • Phase the rollout, starting with billing-critical workflows
      • Train partners; measure documentation time
      • Report the scorecard monthly to board and payers
      • Build the renewal evidence file

    Ten RFP questions to ask every vendor

    1. 1.Which steps of the end-to-end demo are native, separately licensed, partner-run or manual?
    2. 2.Which of our actual health plans have you submitted HRSN claims to in the last 12 months?
    3. 3.Who works denials and appeals, and how is that priced?
    4. 4.How do partner CBOs get paid, and how fast after remittance?
    5. 5.Which FHIR version and Gravity profiles are in production today?
    6. 6.Can we export all of our data in a standard format, at any time, at no cost?
    7. 7.What consent, audit and 42 CFR Part 2 controls exist at the module level?
    8. 8.Which customers of our size and model can we call?
    9. 9.What is the full three-year cost, including implementation and services?
    10. 10.What's on your roadmap versus available in production now?

    Chapter 12 · Getting help

    When executive-level advisory pays for itself.

    Most hub leaders are running the network while redesigning it. A focused advisory engagement compresses months of analysis into decisions.

    • The stakes are high

      A platform or contract decision locks in costs and workflows for three to five years.

    • The rules are specific

      Every waiver, plan and state has its own codes, credentialing and reporting requirements.

    • Time is short

      Renewal cycles and new service openings reward organizations that are ready first.

    What a good engagement delivers

    • Current-state assessment of contracts, finances and systems
    • Financial model with full-cost pricing
    • Operating model and network governance design
    • Technology roadmap and vendor-neutral selection
    • Implementation and change-management plan
    • Measurement and evaluation plan

    How to choose an advisor

    • Independence: ask every advisor to disclose vendor relationships — including us.
    • Sector depth: experience with your waiver, your plans and your state.
    • Deliverables you own: models, scripts and plans you can reuse without them.

    CH360 offers strategy sessions for hub leaders. We sell software, so weigh our advice with that in mind — the same test we suggest for anyone.

    Sources

    Figures describe the sector and named programs, not CH360 customer results. Waiver amounts are spending ceilings approved by CMS, not funds awarded or spent. Survey figures describe respondents, not every organization. Vendor ratings reflect public documentation and are not tested performance. Research current as of November 2026.

    1. [1] U.S. Government Accountability Office, Medicaid demonstrations: HRSN approvals and spending authority (GAO-25-107445) (2025)
    2. [2] CMS, CMCS Informational Bulletin rescinding HRSN guidance (2025)
    3. [3] KFF, Allocating CBO's estimates of federal Medicaid spending reductions across the states (2025)
    4. [4] KFF, Section 1115 Waiver Watch: early signs point to new directions (2025)
    5. [5] Nonprofit Finance Fund, 2025 State of the Nonprofit Sector Survey (2025)
    6. [6] Nonprofit Finance Fund, Amid shutdown and a faltering economy, governments must fund nonprofits (2025)
    7. [7] National Council of Nonprofits, 2023 Nonprofit Workforce Survey (2023)
    8. [8] American Journal of Public Health, Intent to leave among public health community health workers (2024)
    9. [9] USAging Aging and Disability Business Institute / Scripps, At the Nexus of Social Care: 2023 contracting survey brief (2024)
    10. [10] Partnership to Align Social Care, Functions of a Mature Community Care Hub (2023)
    11. [11] HHS ASPE / ACL, Health and social care coordination: Community Care Hub case studies (2023)
    12. [12] USAging Center of Excellence to Align Health and Social Care, Community Care Hub infrastructure award announcement (2024)
    13. [13] USAging Center of Excellence to Align Health and Social Care, National Map of Community Care Hubs (2025)
    14. [14] Administration for Community Living, 2025 Community Care Hub National Learning Community participants (2025)
    15. [15] USAging Aging and Disability Business Institute, Centers for Independent Living and health care contracting (2025)
    16. [16] USAging Aging and Disability Business Institute, Data brief: Community Care Hubs and the networks they lead (2026)
    17. [17] Washington Health Care Authority, Accountable Communities of Health (current)
    18. [18] Washington HCA / OHSU Center for Health Systems Effectiveness, Medicaid Transformation Project summative evaluation (2024)
    19. [19] California Department of Public Health, Office of Health Equity, California Accountable Communities for Health Initiative update (2023)
    20. [20] New York State Governor's Office, $500 million Social Care Networks program (2024)
    21. [21] New York State Department of Health, Social Care Networks: introduction for providers (2024)
    22. [22] New York State Department of Health, SCN data and IT provider fact sheet (current)
    23. [23] North Carolina DHHS, Healthy Opportunities Pilots (2026)
    24. [24] North Carolina DHHS, Healthy Opportunities Pilots lead to healthier outcomes and reduce NC Medicaid costs (2026)
    25. [25] North Carolina DHHS / UNC Sheps Center, Healthy Opportunities Pilots evaluation summary (2026)
    26. [26] Center for Health Care Strategies, Coordinating Medicaid health-related social services through Community Care Hubs (2025)
    27. [27] California DHCS, Enhanced Care Management and Community Supports continue to grow (2025)
    28. [28] Massachusetts EOHHS, Flexible Services Program guidance, contract years 2023–2024 (2022)
    29. [29] Massachusetts EOHHS, $10 million to community-based housing and nutrition organizations (2025)
    30. [30] Camden Coalition, New Jersey Regional Health Hubs (current)
    31. [31] CMS, Pennsylvania Keystones of Health section 1115 demonstration (2024)
    32. [32] CMS / Illinois HFS, Illinois Healthcare Transformation 1115 approval (2024)
    33. [33] CMS / RTI International, Accountable Health Communities Model final evaluation (executive summary) (2026)
    34. [34] CMS, AHC Model connects people to community resources and generates $200M in savings (2026)
    35. [35] Camden Coalition, Staying the course: 2025 annual report (2026)
    36. [36] Camden Coalition, From partnerships to ecosystems of care: 2024 conference recap (2024)
    37. [37] New England Journal of Medicine, Health care hotspotting — a randomized, controlled trial (2020)
    38. [38] Camden Coalition, Results and lessons from the Camden Coalition's randomized controlled trial (2020)
    39. [39] USAging ADBI / Scripps, Embracing the Shift (2024)
    40. [40] Washington Health Care Authority, MTP data dashboards (current)
    41. [41] n4a / Scripps Gerontology Center, Information technology in Area Agencies on Aging (2015 national survey) (2015)
    42. [42] Washington Health Care Authority, Community Information Exchange landscape in Washington (2022)
    43. [43] ONC (now ASTP), Social Determinants of Health Information Exchange Toolkit (2023)
    44. [44] Partnership to Align Social Care, Partnership overview (2022)
    45. [45] CMS, Accountable Health Communities HRSN screening tool (2017)
    46. [46] NACHC, PRAPARE (2024)
    47. [47] HL7 / Gravity Project, SDOH Clinical Care implementation guide (current)
    48. [48] HHS, 42 CFR Part 2 final rule fact sheet (2024 (updated 2026))
    49. [49] Partners in Care Foundation, Community Care Hub (current)
    50. [50] 211 San Diego / CIE San Diego, Community Information Exchange Toolkit (2018)
    51. [51] ASTP / ONC, Health IT Playbook: health information exchange (current)
    52. [52] CRISP (Maryland), Social needs data user guide (2024)
    53. [53] Manifest MedEx, MX Engage (current)
    54. [54] Manifest MedEx, Statewide social health information exchange with NinePatch (2025)
    55. [55] Indiana Health Information Exchange, How IHIE and HIEs strengthen population health (2025)
    56. [56] ASTP / ONC, Trusted Exchange Framework and Common Agreement (TEFCA) (current)
    57. [57] NCCARE360, About NCCARE360 (current)
    58. [58] Unite Us, Unite Us acquires NowPow (2021)
    59. [59] Unite Us, Social care revenue cycle management (current)
    60. [60] Unite Us, Unite Us and Nomi Health partner (2025)
    61. [61] findhelp, Solutions for 1115 waivers (2024)
    62. [62] findhelp, Payments and invoicing (current)
    63. [63] findhelp, New York SCNs impact (2025)
    64. [64] Activate Care, CareLink (current)
    65. [65] Activate Care, CareLink billing services (current)
    66. [66] WellSky, Community-based organizations (current)
    67. [67] WellSky, Healthify is now WellSky Social Care Coordination (2022)
    68. [68] Bonterra, Case management roadmap and questions (2023)
    69. [69] Salesforce, Nonprofit Cloud program management (current)
    70. [70] Socially Determined, SocialScape (current)
    71. [71] Epic, EHR optimization mitigates SDOH, promotes care coordination (2021)
    72. [72] Pieces Technologies, Introducing the new Pieces (2020)
    73. [73] Pear Suite, All-in-one care management software for community health workers (current)
    74. [74] Pear Suite, Solutions for community providers and regional hubs (current)
    75. [75] Pear Suite, Case study: Health Net and Pear Suite empower 1,000+ community health workers (2026)
    76. [76] Office Ally, EDI clearinghouse (current)

    Turn the playbook into your plan.

    A working session shaped around your model, your payers and your state.

    Book a strategy conversation See CH360 for Care Hubs
    Community