Key Considerations for Health Plans: Partnering with Community-Based Organizations to Address Social Determinants of Health

Resources for Integrated Care
March 2021


This brief offers guidance on partnering with community-based organizations (CBOs) to provide services such as meal delivery and transportation for dually eligible individuals.


In recent years, health care providers and payers have begun developing partnerships with CBOs to address social determinants of health, improve quality of life, and reduce health care utilization. Health plan partnerships with CBOs to serve individuals dually eligible for Medicare and Medicaid will continue to accelerate because of the recent authorization of Special Supplemental Benefits for the Chronically Ill. This brief outlines key considerations for plans interested in partnering with CBOs to address the health-related social needs of dually eligible members and shares case studies of effective partnerships.


Key steps that plans can take to develop effective partnerships include:

  1. Conducting an organizational readiness assessment to understand plans’ capacity to implement change, which includes buy-in from staff and leadership. The assessment should examine the problem being targeted, identify the potential business case, define what success would look like, and create a plan to track savings generated by the intervention.

  2. Identifying and choosing a partner by assessing how CBOs operate, including their reach, the population they serve, and the services provided.

The brief features examples of a health plan organizational readiness assessment and partner selection process. It also profiles Health Plan of San Mateo, which partnered with the Institute on Aging and Brilliant Corners to better support members transitioning from nursing facilities to the community.


Health plans beginning to think about partnering with CBOs to address their dually eligible members’ health-related social needs can use this brief to guide their early planning stages.

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