Aw

Issue Brief

CHCF

 

AUGUST 2022

by Anna Spencer, MPH,
and Isabel Clemente, MSW

The Role of Community-Based Organization
Networks in CalAIM: Seven Key Considerations

Services (DHCS), counties, and Medi-Cal man-

aged care plans (MCPs) are ramping up to
meet the ambitious objectives of CalAIM (California
Advancing and Innovating Medi-Cal), a five-year
statewide health care reform plan that centers on a
population-based approach, prevention, and whole-
person care.' Successful collaboration between MCPs
and community-based organizations (CBOs) of all
sizes will be important to CalAIM's success, yet bar-
riers exist for both MCPs and CBOs to create these
collaborations.

T= California Department of Health Care

CBO networks - a group of CBOs led by a network
lead entity (NLE), or neutral convener, for the purpose
of contracting with a health care organization - may
help. This brief focuses on explaining the roles, oppor-
tunities, and challenges that CBO networks present in
the context of CalAIM. Based on a series of key infor-
mant interviews (see appendix on page 14), it outlines
considerations for the potential use of CBO networks,
including the potential benefits and hurdles from the
perspective of CBOs and MCPs. It also identifies the
resources and supports needed to foster the develop-
ment of effective CBO networks.

Introduction

In January 2022, DHCS began implementing CalAIM
with a vision to extend supports and services beyond
health care settings and to meet Medi-Cal members
where they are by addressing their full range of clinical
and nonclinical needs.

Enhanced Care Management (ECM) and Community
Supports (CS) are foundational components of CalAIM

(see box on page 2). ECM is a new statewide Medi-Cal
benefit available to select "populations of focus" that
will address clinical and nonclinical needs of the high-
est-need enrollees through intensive coordination of
health and health-related services." Enrollees will have
a single lead care manager who will coordinate care
and services across the physical, behavioral, dental,
developmental, and social services delivery systems,
meeting enrollees wherever they are - on the street,
in a shelter, in their doctor's office, or at home - to
make it easier for them to get the right care at the
right time.

Community Supports, also known as In Lieu of
Services, are new statewide services offered by MCPs
as cost-effective alternatives to traditional services or
settings designed to address the health-related social
needs of Medi-Cal members. DHCS has approved 14
Community Support services, and MCPs are encour-
aged to offer as many as possible (see box on page 2).

As part of ECM and the delivery of CS, MCPs will be
required to partner with community-based organiza-
tions to provide the array of nonclinical social services.
CBOs interested in participating in CalAIM will need
to negotiate contracts with MCPs, achere to new pri-
vacy and reporting requirements, and adapt to new
workflows, which for many will be a departure from
their traditional operations.

While large and well-resourced CBOs may have an
infrastructure in place to partner with MCPs, small to
midsize CBOs are less likely to have the capacity and
experience to enter into contractual relationships, be
able to take on financial risk, or have the capability
to build staff skill sets and bandwidth.* According to
the National Council of Nonprofits, 88% of nonprof-
its have an operating budget of less than $500,000,
employ 10 or fewer, and often rely on volunteers to
support programming and operations, which may
limit smaller California CBOs in their ability to engage
in CalAIM.4

Despite their small size, however, these CBOs play
a vital role in addressing the nonclinical needs of

Foundational Components of CalAIM

Populations of Focus for Enhanced Care Management
> Individuals and families experiencing homelessness

> People who receive a lot of acute services

community members, including providing job train-
ing, housing and tenancy support, behavioral health
services, violence prevention, and food and nutrition
services. Additionally, as trusted community providers,
CBOs are critical partners in achieving health equity
by elevating the voices of marginalized communities
and vulnerable community members, and providing
culturally relevant, equitable, and strategic solutions
to community challenges.®

> Adults with serious mental illness / substance use disorder and children/youth with serious emotional disturbance

or identified to be at clinical high risk for psychosis or experiencing a first episode of psychosis

> People transitioning from incarceration

> People at risk for institutionalization and eligible for long-term care services

> Nursing facility residents who want to transition to the community

> People enrolled in California Children's Services with additional needs beyond the qualifying condition

> People involved in, or with a history of involvement in, child welfare (including foster care up to age 26)

Community Supports Services*
> Housing transition navigation
> Housing deposits
> Housing tenancy and sustaining
> Short-term and posthospitalization housing
> Recuperative care / medical respite
> Respite services

> Day habilitation programs

> Nursing facility transition / diversion to assisted living facilities

> Personal care / homemaker services

> Environmental accessibility adaptations / home modifications

> Medically tailored meals
> Sobering centers

> Asthma remediation

*Source: Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide (PDF), DHCS, June 2022.

 

California Health Care Foundation

www.chcf.org 2
As DHCS, counties, and MCPs ramp up to deliver
ECM and CS, CBOs of all sizes will be important play-
ers in meeting the ambitious objectives of CalAIM
of delivering person-centered, whole-person care,
addressing the social drivers of health, reducing dis-
parities, and improving quality outcomes.® Yet barriers
exist for both MCPs and CBOs to collaborate in this
new environment. Contracting with several CBOs to
deliver ECM and CS may create challenges for MCPs,
such as the time and expense to execute contracts
with multiple providers, providing oversight, ensuring
fidelity to programs and services, and ensuring data
and security compliance.' Conversely, while CBOs
may be well-positioned to deliver ECM and CS, many
may lack the experience and ability to enter into rela-
tionships with MCPs. CBO networks (see sidebar) are a
potential model that may help to overcome challenges
for MCPs and CBOs by streamlining contracts, help-
ing CBOs engage with MCPs collaboratively, scale the
delivery of nonclinical services, and help to balance
negotiation and collaboration power between the
entities.

A CBO network is a group of CBOs led by a net-
work lead entity (NLE), or neutral convener, for the
purpose of contracting with a health care organiza-
tion. These networks are scalable and can provide
streamlined contracting for multiple services or
interventions. An NLE serves as the hub for coor
dinating services of the wider network, provides a
unified and consistent approach to delivery across a
geographic area, provides administrative oversight,
and leads governance responsibilities.

Source: Martie Ross and Paul Cantrell, Resource Guide -
Building a CBO Network for Health Care Contracting:

Choosing the Right Model (PDF), Aging and Disability Business
Institute, January 2022.

To inform a better understanding of the roles, oppor-
tunities, and challenges that CBO networks might
present in this new policy landscape, the Center for
Health Care Strategies (CHCS), through support from
the California Health Care Foundation, conducted key

informant interviews with subject matter experts, rep-
resentatives from California-based and national CBO
networks, as well as MCPs (see appendix for a list of
interviewees). This brief outlines considerations for the
potential use of CBO networks in CalAIM based on
the interviews, including detailing potential benefits
and hurdles associated with the formation of these
networks from the perspective of CBOs and MCPs,
and identifying the resources and supports needed to
foster the development of effective CBO networks.

CBO Networks: Definition,
Financing, Results

CBO networks come in various shapes and sizes.
Nonprofit Finance Fund recently released a report
that captures the wide range of CBO network types
throughout the country. While some networks are
place-based and coordinate on an array of services,
others serve a specific population (e.g., older adults or
families with children) or a specific issue (e.g., housing
instability or food insecurity). In practice, some net-
works operate with a backbone entity that provides
administrative or contracting support, or both, on
behalf of CBOs within the network. These backbone
organizations, also known as network lead entities
(NLEs), are often nonprofit organizations that serve
as a hub for coordinating services of a wider network
of CBOs. An NLE can provide administrative over-
sight, assume governance responsibilities, and serve
as a fiscal and contracting agent acting on behalf of
CBOs within the network structure. This brief explores
a range of network models, including those that per
form administrative functions on behalf of member
CBOs (see sidebar on the United Way of San Joaquin
County, page 5), as well as contracting and program
coordination functions (see sidebar on C3 Community
Assistance Program, page 6, and the San Diego
Wellness Collaborative, page 9).

According to Nonprofit Finance Fund, network
functions are financed in a number of ways, includ-
ing through grants and contributions from local

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations 3
philanthropy and governments and from contracts
with state, county, and local agencies, as well as health
care organizations, membership dues from partici-
pating CBOs and health care partners, other earned
incomes (e.g., from services provided), and in-kind
contributions.'

Existing evidence supports the idea that CBO net-
works can improve efficiencies for network members,
have a positive impact on health outcomes, and offer
significant return on investment.

Pathways Community HUB

The Pathways Community HUB, for example, is a
well-established model that leverages community
health workers to identify and connect those at the
greatest risk for poor health outcomes to necessary
medical, social, and behavioral health services."°
The HUB, or neutral convener at the center of the
model, provides administrative functions for partici-
pating clinical and community-based providers and
is a centralized point of access for health care part-
ners to refer people to services."' A recent evalua-
tion demonstrated that high-risk pregnant women
who participated in the Pathways Community HUB
model were significantly less likely to deliver a baby
that required neonatal care, compared to women
who did not participate in the model, and their
participation resulted in significant cost savings."
A Pathways Community HUB is currently emerging
in the San Joaquin region, with the San Joaquin
Community Foundation acting as the local HUB.

Seven Considerations
for Using CBO Networks
in CalAIM

The following section captures themes heard through-
out the key informant interviews. While contracting
relationships between MCPs and CBOs to deliver
ECM and CS are nascent, and the development of
CBO networks providing these services are rela-
tively uncommon, informants shared lessons on CBO
collaboration and insights on the benefits of CBO net-
work formation from CBO and MCP perspectives, the
required elements to support successful CBO network
formation, and perceived challenges.

1. CBO Networks Can Increase

Efficiency for CBOs and MCPs

CBO networks can offer efficiencies for both CBOs
and MCPs. CBOs have long been in the business of
addressing clients' nonclinical needs and have a deep
understanding of diverse characteristics of their com-
munities. A CBO network could support an MCP's
understanding of the communities they are serving,
a critical component of addressing health equity, by
being a collective voice for the range of needs and
priorities within a given MCP service area. An effec-
tive network could address MCPs' desire to streamline
contracting for ECM and CS with one lead entity,
rather than pursuing multiple contracts, and could
also provide MCPs with a reliable infrastructure that
could support reporting requirements and consistency
across programs and services. MCP representatives
interviewed noted that partnering with an NLE, rather
than one-on-one with CBOs, offers a single contract-
ing relationship with a wide range of CBOs and also
potentially provides MCPs with a diverse and expert
workforce to deliver ECM and CS at a larger scale.
MCP interviewees noted that the administrative sim-
plicity of contracting with an NLE, particularly within a
specific region, could potentially reduce the fragmen-
tation of care delivery, and improve access and health
outcomes for members.

 

California Health Care Foundation

www.chcf.org 4
From the perspectives of CBOs and others inter-
viewed, many do not have the capacity or financial
resources to build required data infrastructure and
privacy systems or have the in-house expertise to
negotiate contracts with MCPs. CBO respondents
noted that an experienced NLE could help CBOs navi-
gate the complex landscape of contract negotiations
with MCPs, manage reporting requirements, assist
with business operations, and assume responsibility
for provider credentialing and certification (see side-
bar on United Way of San Joaquin County).

Per guidelines from the Centers for Medicare &
Medicaid Services (CMS) and DHCS, providers are
required to procure a National Provider Identifier
(NPI) to deliver services, including ECM and CS.%
CBO informants noted that this was a time-consum-
ing, intensive process and something many smaller
CBOs may have difficulty completing. Additionally,
MCPs have their own independent CBO vetting pro-
cesses, which adds additional administrative burden
and expense for CBOs. Interviewees noted that an
NLE could support CBOs in these certification and
credentialing processes, which would decrease CBO
burden and increase their ability and willingness to
participate in CalAIM. Interviewees also noted that a
CBO network could free up CBOs to deliver services,
rather than "getting bogged down" with the admin-
istrative components associated with partnering with
health care entities, including MCPs. A few respon-
dents shared that in addition to an effective NLE, CBO
network partners are also a critical source of support
and information for each other, and that establishing
cross-CBO learning opportunities can support effec-
tive networks and their operations.

United Way of San Joaquin County:
Supporting Community Collaboration
Nearly 70% of CBOs in San Joaquin County have
operating budgets of less than $55,000, making the
administration of business processes challenging.
Recognizing the limited capacity of many CBOs,

the United Way of San Joaquin County serves as a
fiscal sponsor, providing back-office operations like
human resources, payroll, benefits administration,
claims processing, and invoicing. CBOs pay a mod-
est annual fee to the United Way to provide these
services, freeing up staff to deliver on their core
missions. In addition, the United Way of San Joaquin
County serves as a neutral convener of the Connect-
ed Community Network (CCN),* a multistakeholder
collaboration designed to address the health-related
social needs of San Joaquin Valley community
members. In partnership with San Joaquin County,
2-1-1, and Dignity Health, the United Way provides
CBOs access to the community resource and referral
platform Unite US. The CCN vision is to create a
network of clinical and community partners all work-
ing together to provide appropriate medical and
social need referrals to county residents, with a spe-
cial focus on vulnerable, at-need populations. Unite
US streamlines coordination by linking organizations
that provide direct services to their communities,
and allows community service providers to send,
receive, and track referrals to resources, as well as
provide the tools to collect data on needs, resolu-
tions, and outcomes.

Funding for the CCN comes from an innovative
model called the "community bank" concept.
Funding partners, including health systems, payers,
state and city governments, and local businesses,
sign three-year contracts to commit funding to the
community bank. Stakeholders also pay annually to
support community infrastructure costs, including
the 2-1-1 call center, and an administrative fee for
the United Way, which serves as the fiscal agent,
establishes funder relationships, identifies opportu-
nities for growth, maintains contracts, and ensures
community and CBO capacity to deliver services.

* "Connected Community Network (CCN)," United Way of
San Joaquin.

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations
Project Access Now: C3 Community
Assistance Program

Project Access Now (PANOW), a Portland-based
CBO, operates a network of CBOs to connect
patients discharging from the hospital, as well as
qualified Medicaid members, with needed health
care, nonmedical services, and other community
resources. The C3 Community Assistance Program
(C3CAP) is supported by local hospital systems
and the state's Medicaid managed care organiza-
tions - coordinated care organizations - and is
designed to help those people successfully transi-
tion from the emergency department and inpatient
hospital settings back to their homes by addressing
health-related social needs that impact health and
recovery. Support staff at hospitals and health plans
collaborate with C3CAP specialists to identify at-risk
patients through a screening process and connect
those eligible to needed services, such as trans-
portation, respite care, medication assistance, and
temporary housing.

Participating health care entities pay PANOW
directly for the goods and services required, as well
as a tiered administrative fee based on the referral
volume. PANOW acts as a "utility" for health care
entities by managing referrals, coordinating pay-
ments, overseeing procurement of services, and
maintaining the network of participating CBOs.
PANOW facilitates contracts with CBOs, which
allows them "to do what they do best" by deliver-
ing care and nonclinical services. The network also
relieves significant administrative burden for health
care partners, as PANOW coordinates and contracts
with over 200 CBOs in the Portland region. Each
year, C3CAP provides over $3 million in goods and
services, serves 10,000 community members, and
fills more than 20,000 service requests.

Source: C3 Community Assistance Program: Here for

Community, Here for Providers (PDF), Project Access Now,
accessed July 26, 2022.

2. Opportunity Costs Are High
for CBOs

The CBO representatives who were interviewed
reflected that establishing a network requires sig-
nificant time and trust between partners. Network
interviewees reported that CBOs had a long history of
collaboration, as well as experience working with the
health care sector, which primed discussions around
network development. In addition to trust and long-
standing relationships, CBO network respondents
noted that significant time was required to align on a
vision and mission for the network, agree on a gover-
nance structure and internal management processes,
establish technology systems across the network, as
well as agree upon service and program delivery stan-
dards and reporting requirements. Some informants
noted that without up-front capital, it will be very dif-
ficult for CBOs to come together to create a network.
Citing "few reserves" and a "stretched workforce,"
interviewees noted that there is simply not the staff
capacity or resources necessary to explore network
formation, let alone create a networked structure.

Several interviewees suggested that a lot of education
is required to persuade CBOs to come together to form
a network entity. Historically, because of very limited
revenue sources, compared to health services entities,
CBOs often operate with a "scarce resources" mental-
ity and on business models centered on grant-funding
sources. CBO leaders are "very protective" of their
clientele, and relinquishing some control to a larger
network structure, or lead organization, and moving
from competitors to collaborators, is a potential bar-
rier. Some interviewees noted that profit advantages
need to be clearer to CBO CEOs for them to be will-
ing to share power with a third party. That said, some
CBO respondents noted that shared learning oppor-
tunities and dissemination of best practices among
CBOs has been an effective strategy for encourag-
ing partnership activities and network development.
In addition, when MCPs have provided training and
capacity building support to CBOs, this process has
helped to address the significant opportunity costs

 

California Health Care Foundation

www.chcf.org 6
associated with developing partnerships to address
social needs, as well as initiating conversations about
network development.

"You'd need a very savvy and well-resourced
organization to serve as a backbone
entity. They would need a lot of flexibility,
capital on hand, and back-end support to
coordinate across CBOs. And then this
organization would have to act in the best
interest of all the CBOs in the network,
which seems like a hard thing to achieve."

- CBO representative

In the California context, interviewees noted that many
CBOs are negotiating contracts directly with MCPs
rather than working through an NLE. These CBOs
have long-standing relationships with MCPs, as well as
the counties in which they operate, and the amount of
legwork to develop a network was deemed not in the
best interest of the CBO. Several CBO respondents
noted that the administrative rate available through
ECM and CS contracts is relatively low, making hir
ing additional staff to oversee the coordination of
services across organizations difficult to cover. There
is also a tension for CBOs to independently contract
with MCPs, especially during the rollout of CalAIM, to
avoid missing out on a partnership opportunity. This
desire by individual CBOs to establish contracts with
MCPs, which in many instances has been successful,
makes the need to establish a network less imperative.

Respondents repeatedly cited technology require-
ments as a barrier to CBO network formation. CBOs
may use different technology platforms - some-
times to meet MCP requirements - and investments
in additional technology systems is prohibitively
expensive. While technology will play a substantial
role in streamlining billing, referrals, communication,
and data collection and reporting, high-functioning

networks will be "built on relationships, not tech-
nology." Making the case to MCPs on the value of
services or programs provided requires data, but the
burden to collect data in a way that resonates with the
health plans falls to CBOs. While a network structure
could support data collection and analysis, there are
significant associated up-front costs.

3. Leadership, Vision, and Resources
Are Required

While many CBOs understand the value of forming a
network to deliver ECM and CS, gaps in understand-
ing effective models persist. Leadership, vision, and
resources are key ingredients to establishing effective
networks. An effective leader, including an NLE, could
broker relationships and contracts among both CBOs
and MCPs, and could spearhead discussions around
identifying the specific functions and roles within CBO
networks, help to operationalize the key functions of a
network structure, and advocate on behalf of the net-
work in the health care system more broadly.

Findings from a Nonprofit Finance Fund report,
developed through its Advancing Resiliency and
Community Health (ARCH) initiative, shed light on the
experiences CBO networks face when contracting with
health care entities and plans. These include the signif-
icant opportunity cost required to explore partnership
relationships, lack of clear payment mechanisms and
rates, misaligned missions and business models, and
an expectation that CBO networks will make signifi-
cant investments to participate in pilot projects to
demonstrate a return on investment without the guar-
antee of a long-term contract or sustainable revenue.
CBO networks in the ARCH initiative (see sidebar,
page 8) sought to transform the health care system
by coordinating care with health care organizations,
but divergent missions and care delivery approaches
made contract negotiations unworkable for the most
part."* To encourage equitable and accessible part-
nerships between CBO networks and MCPs, learning
opportunities for MCPs that promote the understand-
ing of CBO strengths and core functions could enable

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations 7
MCPs to be more responsive and adaptive to the
needs and capabilities of CBOs and their networks to
deliver ECM and CS, as well as other programs and
services.

In the CalAIM context, informants perceived little flex-
ibility for CBOs to negotiate ECM and CS contracts,
and that CBOs are in a "take-it-or-leave-it situation,"
which would be true regardless of whether CBOs were
part of a network. Some suggested that without a sig-
nificant caseload of ECM-eligible Medi-Cal members,
negotiating contracts with MCPs will be challeng-
ing, as will hiring full-time case managers to deliver
ECM because of insufficient revenue. Interviewees
reflected that, while some have successfully negoti-
ated contracts with MCPs in the past, for other CBOs
this uncertainty makes it challenging to take on ECM
and CS contracts, and networking to do so is less

appealing.

Advancing Resiliency and Community
Health Initiative

The Advancing Resiliency and Community Health
initiative was launched by Nonprofit Finance Fund
in response to the growing momentum around

the idea that partnership and contracts between
CBOs and health care organizations could provide
new funding streams for services addressing social
determinants of health. Nonprofit Finance Fund
partnered with three CBO networks - EngageWell
IPA of New York, Thomas Jefferson Area Coalition,
and Metropolitan Alliance of Connected Com-
munity of Minnesota - to explore what it takes for
CBO networks to partner with health care. A series
of resources was produced on lessons for building
partnerships and pursuing contracts with health care
organizations.

For more information, see Lessons Learned from Partnerships

Between Networks of Community-Based Organizations and
Healthcare Organizations, Nonprofit Finance Fund, 2021.

4. A Neutral and Trusted Convener
Is Required

Many networks have formed organically and have
developed over decades of collaboration. The part-
ners in established networks have a long history of
working together, including through pilot programs
and initiatives, and have developed trust and under-
standing of each other's missions, staff capabilities,
and service delivery approaches. Many networks form
over a shared mission or goal, and in California, many
clinical and community partners have established con-
nections through the Medicaid Health Homes and
Whole Person Care pilots.

For any network to flourish, interviewees reflected that
significant amounts of time and space are needed to
pull stakeholders together, start building relationships,
explore the priorities of each entity, and agree on the
purpose and identity of a network. At the core of suc-
cessful CBO networks has been a neutral convener
with the skill to "lessen competition among CBOs and
increase collaboration."

This neutral convener will need to be skilled at facili-
tation, brokering cross-sector relationships, and
understanding power dynamics among network
partners, and will help move relationships from com-
petitive to collaborative. A neutral party can help
identify the key functions and responsibilities of the
network, define the services that each partner CBO
will provide, and establish a mutually agreed upon
governance structure.

"These are not transactional relationships,
they are transformational, which means you
have to dedicate the time and resources to
ensure they are successful."

- CBO network representative

 

California Health Care Foundation

www.chcf.org 8
Brokering and negotiating on the above, however,
takes a significant amount of time but is critical to
building trust and understanding among partners.
Supporting and scaling networks already in exis-
tence - for example, the Accountable Communities
of Health (ACH) - builds on established trust among
partners and may help to lay the groundwork for part-
ners to formalize network functions and capabilities.
California's ACH sites bring together a diverse range
of partners to address the constellation of community
health and social needs, and include neutral conve-
ners such as local health departments, CBOs, and
community organizing entities. Recognizing the suc-
cess and potential of the ACH model, in June 2022,
Governor Gavin Newsom approved a $15 million bud-
get line item that will support the expansion of ACHs
to 25 new sites throughout the state.'® Interviewees
noted that building the capacity of existing ACHs
and creating additional sites will create the needed

infrastructure for MCPs to partner with communities to
deliver whole-person care services, such as ECM and
CS, as well as partner on other programs and initia-
tives designed to improve population health.

Additionally, CBO informants shared perspectives that
MCPs are behemoths, "a little opaque," and can be
disconnected from the very vulnerable populations
that CBOs typically serve. CBOs representatives also
cited "informational asymmetry" with MCPs, with
MCPs holding all the information on program require-
ments, contracts, and reporting standards, which
has created a challenging dynamic for CBOs to get
information and move processes forward. Differing
lexicons for service delivery and reimbursement were
also cited, including different measures of success,
which makes developing and navigating partnerships
difficult. An NLE could help CBO partners navigate
this information challenge, provide some translation

San Diego Wellness Collaborative: A Backbone Across Initiatives

Neighborhood Networks has been operating as a network since 2019. Health care organizations and MCPs can

contract with Neighborhood Networks to deliver ECM and CS, as well as other programs focused on addressing
health-related social needs. Neighborhood Networks leverages the power of "neighborhood navigators" employed
by CBOs that have developed deep, trusting partnerships and understand the local assets and barriers to health in
the communities they serve.

As a network, Neighborhood Networks utilizes one standardized case management and claims system, ensures CBO
partners are compliant with MCP data and security requirements, and assumes responsibility for contracting and
reporting, as well as providing education and training to community-based workforces. CBOs who are contracted

in the network receive a cost-based reimbursement from Neighborhood Networks with the opportunity to move to
incentive-based payments.

Neighborhood Networks is a part of the San Diego Wellness Collaborative, a nonprofit organization seeking to
improve population health and to advance equity in San Diego through three major multistakeholder collaborative
initiatives. SDWC serves as the lead entity for San Diego's Accountable Community for Health (GSDACH) program,

part of the broader California Accountable Communities for Health Initiative (CACHI), which uses a cross-sectoral ap-
proach to address clinical and nonclinical needs. SDACH has convened over 100 local leaders to "flip the script" and
adopt a collaborative approach that prioritizes community well-being over treatment. The first priority for SDACH was
to address cardiovascular health across the lifespan through "Be There San Diego" - a coalition of patients, commu-
nities, and health care systems working together to prevent heart attacks and strokes. Through years of partnership
and collaboration with community and clinical providers, as well as community members, SDWC has established itself
as a trusted entity that was helpful in forming the network.

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations
on MCP processes (e.g., reporting), and advocate on
behalf of CBOs and their clients to ensure fair con-
tracts. An NLE could help manage the delegation of
services and subcontracts within a network to ensure
well-suited CBOs are delivering a particular service,
assume responsibility for sharing best practices, align
standards, and assure integrity in quality reporting -
all of which are critically important in demonstrating
value and effectiveness of services delivered. CBO
representatives also suggested that an NLE could
support training and education of network partners
through learning collaboratives, technical assistance,
and peer-to-peer exchanges to ensure the spread of
best practices and to support the success of a diverse
set of CBO types (see box below).

5. Putting Equity at the Center

Many interviewees expressed concerns that fac-
tors related to structural racism will likely persist
during the rollout of CalAIM, exacerbating existing
health inequities unless these issues are deliberately
addressed - with input from CBOs and community
members. Interviewees cited fears that multisite and
well-resourced CBOs will be better positioned to join
forces to contract with MCPs, leaving smaller, more
locally focused CBOs, which often exclusively serve
communities of color, at a disadvantage. Respondents
noted that having structures and requirements in place
to ensure diversity among CBO type and populations
served will be important to ensuring equity. Some
states, such as North Carolina, have implemented a
checklist for health plans to ensure diversity of CBOs
participating, including those led by people of color,
in state initiatives (see box below).

Ensuring Equity in North Carolina's Healthy Opportunities Pilot

North Carolina's Healthy Opportunities Pilot, the state's Medicaid 1115 waiver program, is centered on addressing
upstream social determinants of health such as food insecurity, transportation, interpersonal violence, and unstable
housing. A core component of the pilot is NCCARE360, a statewide electronic platform that connects health and
human service providers and supports links to CBOs to address social needs. NCCARE360 includes a call center with
(1) dedicated navigators; (2) a data repository to integrate resource directories across the state; (3) a shared technol-
ogy platform that enables health and human service providers to send and receive secure electronic referrals, com-
municate in real time, and track outcomes; and (4) a community engagement team working with CBOs, social service
agencies, and health systems throughout the state.

As part of the pilot, the state's managed care organizations, or Prepaid Health Plans (PHPs), will be responsible for
developing networks of CBOs. These networks will be established and overseen by a Lead Pilot Entity (LPE), and so-
cial services providers interested in participating in a pilot will need to contract with the LPE in its geographic region.
As part of the contracting process, the LPE will assess CBO readiness and qualifications to participate in pilot activi-
ties. An analysis of the initial wave of CBOs revealed that larger, more experienced CBOs were the first to apply to
contract with LPEs, and smaller, less-resourced providers were not at the table. To ensure diversity among contracted
CBOs, North Carolina's Department of Health and Human Services (DHHS) has implemented a review process to
ensure adequate representation of CBOs led by women or people of color within each network, and that LPEs and
CBO staff are demographically representative of the Medicaid populations in their region. As part of the pilot, DHHS
and the LPE will also provide technical assistance and education aimed at human services organizations in pilot areas
to ensure their success, and contracted CBOs will be required to participate in these readiness activities and trainings.
Capacity-building funds are available to the LPEs to support these efforts, and it is hoped these funds will address
equity concerns and ensure that the less-resourced CBOs will benefit from such opportunities. DHHS is currently
exploring additional incentives for PHPs to increase diversity among organizations.

 

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Moreover, as the health care landscape shifts and pri-
vate equity firms focused on profits enter the health
care space, there are concerns that the interests and
values of smaller CBOs and those serving people of
color will be overlooked. Several informants noted
that for-profit entities are now working to deliver ser-
vices, such as medically tailored meals, and while they
are "efficient," their size and distribution range makes
them more affordable partners than local nonprofit
CBOs. Interviewees cautioned that health equity may
not be in the "hearts and minds" of for-profit entities
that serve as CBO NLEs, and as networks are estab-
lished and MCPs begin to partner with them, attention
to their connections with community will be important.

6. PATH Funding May Support CBO
Network Development

All informants spoken with noted that significant up-
front financial and technical support are required
to stand up CBO networks. This backing includes
financial resources to support staff time to convene
and coordinate CBO network roles and responsibili-
ties, to implement infrastructure enhancements (i.e.,
links to electronic health records and updates to
IT systems), and to train staff - as well as technical
assistance to meet reporting and billing requirements,
new workflows, and understanding CalAIM benefits
and programs. Most CBOs operate on a shoestring
budget, which limits their bandwidth to make space
for these coordinating discussions. Without financial
and technical support, the up-front work required by
CBOs to form networks and successfully contract with
MCPs will feel extractive. PATH (Providing Access and
Transforming Health) funding available through CalAIM
will be a critical source of support to build, maintain,
and scale the capacity necessary to implement ECM
and CS statewide.' PATH funds could be allocated
toward peer-to-peer learning opportunities on CBO
network functions and operations, offering "meeting
space" for CBOs to form and deepen partnerships,
and technical assistance to organizations with an inter-
est in serving as NLEs. Interviewees noted that seed
funding, either through PATH or from philanthropy,

could support CBOs to build relationships with one
another and to chart a course to collaborate on
CalAIM initiatives. As evidenced through the ACH ini-
tiative, communities and CBOs are in various states of
readiness, and funding to initiate conversations about
needs and priorities could support collaboration on a
shared goal and vision.

7. Existing California Networks and
Lead Entities Can Be Leveraged
to Support CBO Network
Development

Though California CBO networks are still quite
nascent, an array of social services networks and
population health-focused conveners and coalitions
already exist across the state (see list of examples on
page 12). These organizations and coalitions have rela-
tionships, skills, and expertise that could be built upon
to accelerate CBO network formation. For example,
13 CACHI lead entities have invested significant time
convening local health and social services stakehold-
ers, building relationships, creating a shared vision,
and understanding the priorities of participating enti-
ties. While the CACHIs may not currently perform
core CBO network functions, their significant up-front
relational investments could be built upon to bring
CBOs together and develop some, if not all, network
functions. Likewise, organizations such as local United
Ways provide a range of health, educational, and
financial services in addition to operating or provid-
ing funding for 211 programs in 32 California counties.
They could be supported to evolve into broader
CBO networks, as the example of United Way of San
Joaquin illustrates.

There are a few key considerations to leveraging exist-
ing infrastructure. With health equity and racial justice
in mind, investments in existing partnerships or orga-
nizations would need to be deliberately structured so
as to prioritize network development inclusive and
supportive of CBOs led by people of color. And while
CBO network functions may not ultimately align with
the long-term role that existing coalitions, conveners,

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations 11
and networks wish to play, they could be helpful
mentors and technical assistance providers to other
organizations interested in building this capacity and
developing a network.

Examples of Networks Led by CBOs
Operating in California with CalAIM
(Community Supports and ECM) Alignment

California Accountable Communities for Health
Initiative (CACHI)

California Area Agencies on Aging

Community Health Worker Agencies
> El Sol
> Vision y Compromiso
> Latino Health Access
> Transitions Clinic Network

Community clinic consortia
Connected Community Network
California Food is Medicine Coalition

Health center-led IPAs
> Community Health Center Network

> Health Center Partners of Southern California
Health Information Exchanges
California Continuums of Care
Institute on Aging

North Coast Health Improvement and
Information Network

Neighborhood Networks

Partners in Care Foundation

Pathways Community HUB Institute (San Joaquin)
Regional Asthma Management and Prevention

United Ways of California
> United Way 211 programs

Conclusion

CalAIM has enormous potential to transform Medi-
Cal to be more person-centered, whole-person
focused, and equitable. As MCPs look to community-
based organizations to help deliver both Enhanced
Care Management and Community Supports, CBO
networks are a potential model to provide some effi-
ciencies for both MCPs and CBOs. A network lead
entity can streamline contracts for MCPs across myr-
iad CBOs, as well as offer technical and translational
support to CBOs as they enter the health care space.
That said, significant time and resources, along with
a trusted neutral convener, are required to ensure
the success of a CBO network model. Opportunities
within CalAIM, including through PATH funding, could
spur connection and new relationships among CBOs
and help to build the capabilities of entities able and
interested in serving as the neutral convener.

 

California Health Care Foundation

www.chcf.org 12
About the Authors

This brief was prepared by Anna Spencer, MPH, senior
program officer, and Isabel Clemente, MSW, program
associate, at the Center for Health Care Strategies.
CHCS is a policy design and implementation partner
devoted to improving outcomes for people enrolled
in Medicaid. CHCS works across sectors and disci-
plines to connect people and ideas to spark insights,
build expertise, strengthen leadership, and spread
innovations. CHCS focuses on making more effec-
tive, efficient, and equitable care possible for millions
of people in the US who face serious barriers to well-
being, like poverty, complex health and social needs,
and systemic racism.

About the Foundation

The California Health Care Foundation is dedicated
to advancing meaningful, measurable improvements
in the way the health care delivery system provides
care to the people of California, particularly those
with low incomes and those whose needs are not
well served by the status quo. We work to ensure that
people have access to the care they need, when they
need it, at a price they can afford.

CHCF informs policymakers and industry leaders,
invests in ideas and innovations, and connects with
changemakers to create a more responsive, patient-
centered health care system.

Endnotes

1.

10.

11.

12.

13.

14.
15.

16.

California Advancing and Innovating Medi-Cal (CalAIM):
Enhanced Care Management (PDA), California Dept. of Health
Care Services (DHCS), accessed May 1, 2022.

. CalAIM Enhanced Care Management, DHCS, accessed

May 28, 2022.

. Stacey Chazin and Tricia McGinnis, "An Inside Look at

Partnerships Between Community-Based Organizations and
Health Care Providers," Center for Health Care Strategies,
October 12, 2017.

. Nonprofit Impact Matters: How America's Charitable

Nonprofits Strengthen Communities and Improve Lives (PDF),
National Council of Nonprofits, August 2019.

. Emily Santich, "Strengthening Relationships Between Health

and Community Organizations to Support Health Equity,"
Colorado Health Institute, August 12, 2021.

. "CalAIM," DHCS, accessed May 2, 2022.

. June Simmons and Sandy Atkins, Building an Integrated

System of Care & Services: Community Partnerships for
Whole-Person Care (PDF), Partners in Care Foundation, accessed
June 27, 2022.

. Lessons Learned from Partnerships Between Networks

of Community-Based Organizations and Healthcare
Organizations, Nonprofit Finance Fund, 2021.

. Lessons Learned, Nonprofit Finance Fund.

"The Pathways Community HUB Institute Model," Pathways
Community HUB, accessed June 22, 2022.

Pathways Community HUB Manual: A Guide to Identify and
Address Risk Factors, Reduce Costs, and Improve Outcomes
(PDF), Agency for Healthcare Research and Quality, January 2016.

Heidi Arthur and Mark Redding, Pathways HUB: The Right
Approach at the Right Time (PDF) (Health Mgmt. Associates and
Pathways Community HUB presentation, January 11, 2018).

"National Provider Identifier Standard (NPI)," Centers for
Medicare & Medicaid Services, last modified December 1, 2021.

Lessons Learned, Nonprofit Finance Fund.

California Accountable Health for Communities Initiative,
"Governor Newsom Gives Stamp of Approval to
Groundbreaking Community Health Initiative" (PDF),
press release, June 30, 2022.

"CalAIM Providing Access and Transforming Health Initiative,"
DHCS, accessed May 10, 2022.

 

The Role of Community-Based Organization Networks in CalAIM: Seven Key Considerations 13
Appendix. Interview List

CHCS conducted interviews with the following key informants in May and June 2022.

Abode Services

Vivian Wan, Chief Operating Officer

Kara Carnahan, Vice President, Programs

California Accountable Communities for Health
Initiative

Barbara Master, Director

California Food Is Medicine Coalition

Ann Thrupp, Director

California Pan-Ethnic Health Network

Cary Sander, Senior Policy Director

Camden Coalition of Healthcare Providers
Victor Murray, Senior Director, Community

Engagement and Capacity Building

Natasha Dravid, Senior Director, Care Management
and Redesign Initiatives

Common§Spirit Health

Ji lm, Senior Director, Community and
Population Health

EngageWell IPA

Kevin Muir, Former Executive Director

Local Health Plans of California

Linnea Koopmans, Chief Executive Officer

MassHealth
Gary Sing, Senior Director, Strategic Initiatives

Tamara Lange, Director of Community Partners
Program

Stephanie Bucker, Deputy Director of Social Services
Integration

Allison Rich, Senior Manager of Social Services

Integration

Nonprofit Finance Fund

Annie Chang, Vice President

Alexandra Chan, Director

North Carolina Department of Health and Human
Services

Amanda VanVleet, Associate Director of Innovation

Erika Walsh, Director, Healthy Opportunities

Project Access Now

Carly Hood-Ronick, Executive Director

Stephanie Marson, Director, Programs

San Diego Wellness Collaborative -
Neighborhood Networks

Kitty Bailey, Chief Executive Officer

Social Current

Ruby Goyal-Carkeek, Senior Vice President,
Programs and Services

United Way of San Joaquin County
Kristen Birtwhistle, President and CEO

 

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