The Role of Community-Based Organizations in Supporting Value-Based Care


In the transition to value-based care, providers today are being asked to do something they are not use to—caring for patients outside of the clinical setting. With incentives aligned on reducing utilization and decreasing re admissions, providers must now focus on prevention and wellness, in addition to delivering quality acute care.

This task, however, of managing population health is easier said than done. Given the many social circumstances that impact an individual’s care, it is often difficult to ensure positive outcomes after discharge.  Without active monitoring, providers can’t always guarantee patients follow the recommend care plan. And they can’t always verify that patients are being discharged to a place with suitable conditions for recovery.


To address these challenges, providers need to establish more robust coordinated care. Health plans and their contracted network of providers must bridge the gap between clinical and social settings of care. And they must align with non medical, community-based service providers (CBOs). Because CBOs understand their local communities and are connected to the groups they serve, they can provide the missing link in coordination to effectively address patient needs and improve prevention.

This model of connecting providers with CBOs has seen significant success in improving patient outcomes, decreasing re admissions, and reducing overall costs.

Bay Area Community Services can certainly attest. The Oakland based group serves both older adults and adults experiencing mental illness, substance abuse, and homelessness.  They partnered with Sutter Hospital/LifeLong Medical Care for medical respite and recuperative care services for homeless adults ending an in-patient hospital stay. BACS provided room and board, wellness checks, and housing coordination services. Through the program, 98% of medical respite participants were not re-hospitalized for their condition, and 30% were transitioned from the medical respite program to permanent housing.

Another example seeing success is Elder Services of the Merrimack Valley, Inc. (ESMV), a Lawrence, Massachusetts-based Area Agency on Aging. ESMV started a community-care transition program that has helped six community hospital systems decrease 30-day re admissions by nearly 40% among at-risk patients. Using a tool guiding health care coaches through a series of simple survey questions, they are able identify changes in an individual’s health condition and help them to receive care at the right time, in the right setting.

As we bridge the gap between clinical and social services, more robust coordination of care is established. And the result of aligning efforts is greater incentives and reduced cost of care, and ultimately a healthier patient population.

At Healthify we are focused on supporting coordinating services with CBOs to better address social determinants. If you’re interested in learning how, please contact us below!

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Topics: community-based organizations coordinated care value-based care

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