Chronic Conditions - Key Activity 20


Strengthen Community Partnerships


This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; address social needs.


Strengthening partnerships with other organizations – such as pharmacies, recreation centers, senior centers, local government, community based organizations (CBOs), etc. – that share the practice’s vision and goals for its patient population enables the practice to provide more holistic care to patients and leverage many of the strengths and resources available in the community. These partners provide various services and programs to the community, such as education, housing, food, transportation, employment and social support.

This activity provides considerations and tips for strengthening partnerships; although note that deep engagement in this work can require significant resources from your practice.

Many community-based organizations have a deep understanding of the needs and preferences of the specific subpopulations, as well as the resources and challenges that exist in the local context. They can support outreach and health literacy efforts, participate in co-design by providing insight around a particular patient population, and provide resources and support for patients.

Building and strengthening relationships with community-based partners can extend the reach and impact of practices by facilitating patient access to services that the practice is unable to provide directly. Through partnerships with organizations that provide housing supports, nutrition assistance, transportation and other social health supports, practices can play an active role in helping to address the social needs of their patients. The PHMI Equity Framework and Approach should inform partnership development to ensure the work of partnership building is prioritizing community groups that experience injustice and structural violence.

An additional aspect of whole-person healthcare is greater coordination and collaboration with existing community mental health supports. As with community partnerships, integration rests on enhanced relationships between organizations. This means going beyond simply being aware of community mental health organizations as receiving referral sites to reaching out to better understand the barriers to information sharing as well as community mental health agencies’ capacities and expertise.

Action steps and roles

1. Start by understanding the resources and partnerships available through Medi-Cal.

Suggested team member(s) responsible: clinic operations and leadership staff who will liaise with community partners.

Resources include supports that are available to all Medi-Cal patients (such as transportation to medical appointments) as well Medi-Cal Community Supports for eligible individuals with higher levels of social needs. The following is a list of social support resources that are available to Medi-Cal patients when eligibility criteria are met:

  • Transportation to medical and other Medi-Cal-covered appointments.
  • In-home supportive services – personal home care assistance for those who qualify.
  • Community-based adult services – day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the14 Medi-Cal Community Supports are:

  • Housing transition navigation services.
  • Housing deposits.
  • Housing tenancy and sustaining services.
  • Short-term posthospitalization housing.
  • Recuperative care (medical respite).
  • Day habilitation programs.
  • Caregiver respite services.
  • Nursing facility transition/diversion to assisted living facilities.
  • Community transition services/nursing facility transition to a home.
  • Personal care and homemaker services.
  • Environmental accessibility adaptations (home modifications).
  • Medically supportive food/meals/medically tailored meals.
  • Sobering centers.
  • Asthma remediation.

Contact the provider services department of your Medi-Cal Managed Care Plan to learn more about the providers of these services and specific providers in your area. With a list of contracted community-based organizations, your practice can start to build relationships and support ongoing social needs for your patients.

For an overview of Community Supports in the state, DHCS has provided information about the current state of Enhanced Care Management and Community Supports in the Community Supports Year 1 Summary and the Enhanced Care Management Year 1 Summary.


2. Complete an environmental scan to understand who your patients identify as trusted messengers and resources in their community.

Suggested team member(s) responsible: health center leadership, community health workers and social work staff.

This can be completed by interviewing patients and families and by confirming existing partner relationships. This can be completed with the assistance of community health workers. After that, a stakeholder map and community profile of key current and prospective partners can be developed.

Practices should also partner with hospitals, community behavioral health centers, public health agencies and other key stakeholders to refine your community needs assessments.


3. Convene partners as a work group to develop strategies and interventions to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

In some cases, your practice may serve as a convener, bringing partners together for collaboration to avoid relying on individual relationships with external organizations. Be clear on your “asks and offers” to ensure the relationship will be mutually beneficial.

Develop a shared aim statement with your partners as to why this work is important and your vision of what you hope to achieve. Following the aim statement, formalize your structure and system of collaboration and accountability to ensure progress. This may take the form of ongoing pacing of meetings on a regular basis rather than relying on transactional relationships. To ensure proper understanding of expectations, roles and commitments, memorandums of understanding should be developed.


4. Collaborate with your partners to develop a shared set of strategies on a community approach to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

The practice should benchmark and collate approaches to identify potential interventions for addressing health-related social needs. CalAIM resources should be leveraged as part of your intervention plans.

A driver diagram should be developed to guide your efforts and to set priorities.


5. Collaborate with partners to co-design and execute interventions and approaches to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

Use workflow mapping tools, swim lane diagrams and checklists that clarify roles and plan initiatives. This allows the practice to develop clear action plans that clarify leaders of intervention strategies, timetables, and measures of progress and success.

Going deeper in strengthening partnerships: Addressing community needs requires sustainable and effective partnerships over time. A future activity includes your organization working with other community partners in an ongoing forum to address community needs. This often involves the health center as a backbone organization supporting a local collaboration governance structure for shared prioritization and action planning.

On the horizon in strengthening partnerships: A mature partnership system in a health center includes assessing the effectiveness of the partnerships and finding ways to continuously ensure alignment so that partnership remains a positive force for all participants. When possible, making adjustments that strengthen the partnerships can be explored (such as improving data sharing, pooling resources to increase leverage in the community, etc.).

Implementation tips

  • Health centers are very adept at developing relationships in the community, but often they are challenged in nurturing partnerships. A partnership starts with relationships, moves beyond referral for resources or support, and results in co-ownership for addressing community challenges.
  • Be clear on being able to have something to offer when approaching a prospective partner. Nurture the relationships and avoid becoming transactional, ensuring the partnership has value for all parties and helps others fulfill their mission.
  • Seek to understand your partner’s needs for results, data and reporting. Explore how the partnership can help your partner meet a need or address a pain point in their core business mission.
  • Learn what is in place for your county through the Medi-Cal program and your managed care plans. If resources are not available, explore technologies that facilitate community referrals, such as and Unite Us’ cross-sector collaboration software.