Preventive Care - Key Activity 15


Strengthen Community Partnerships


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


Strengthening partnerships with community-based organizations that share the practice’s vision and goals for its patient population enables the practice to provide more holistic care to patients and meet crucial patient social needs. Your practice can leverage existing community infrastructure to provide resources unavailable within the medical home. Community partners provide various services that meet patients’ basic needs, such as education, housing, food, transportation, employment assistance 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.

Local social service organizations are rooted within the communities they serve; thus, they have a deep understanding of the needs and preferences of their communities, as well as local resources and challenges. They can support outreach and health literacy efforts and participate in codesign by providing insight around clinical initiatives serving particular patient populations.

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. Through partnerships with organizations that provide housing supports, nutrition assistance, transportation, and other social needs, practices can play an active role in helping to address health-related social needs. 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.

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 as 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, including personal home care assistance for those who qualify.
  • Community-based adult services, including day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the 14 Medi-Cal Community Supports are:

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

For specific providers in your area, contact the provider services department of your Medi-Cal managed care plan to learn more about the providers of these services. 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, social work staff.

  • Interview patients and families.
  • Learn from your community health workers.
  • Confirm your existing partnership relationships.
  • Develop a stakeholder map and community profile of key current and prospective partners.
  • Partner with hospitals, community behavioral health centers, public health, and other key stakeholders to refine your community needs assessments.
  • For pregnant people, community partners you might want to refer your patients to include organizations providing childbirth and parenting classes, midwifery practices, doula services, organizations providing breastfeeding support, home visiting programs, and the local fire and police stations, which can perform car seat checks.


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

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

  • Serve as a convener, bringing partners together for collaboration, and don’t simply rely 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.
  • Formalize your structure and system of collaboration accountability for progress in the form of ongoing pacing of meetings on a regular basis rather than relying on transactional relationships.
  • Develop memoranda of understanding clarifying expectations, roles, and commitments.
  • Outline clear next steps and action items with clear roles and responsibilities to maintain accountability across partner organizations.


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.

  • Benchmark and collate approaches to identify potential interventions for addressing health-related social needs.
  • Leverage CalAIM resources as part of your intervention plans.
  • Develop a driver diagram 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.
  • Develop clear action plans clarifying leaders of intervention strategies, timetables, and measures of progress and success.


  • Health centers are very adept at developing relationships in the community, but may find it challenging to nurture long-term 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 an offer as well as ask when approaching a prospective partner. Avoid transactional relationships with community partners and ensure the partnership has value for all parties.
  • Seek to understand your partner’s needs for results, data and reporting. Explore how the partnership can help your partner meet a need or resolve a pain point in their core mission.
  • Reach out to your local managed care plan (MCP) to determine processes for payment and care management.
  • 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.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.
  • Going deeper in strengthening partnerships: Addressing community needs requires sustainable and effective partnerships over time. A future activity includes how your organization works with other community partners in an ongoing forum to address community needs (e.g., forming a community partner advisory committee). 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 structure 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. Where possible, making adjustments, such as improved data sharing and pooling of resources to increase leverage in the community, that strengthen the partnerships can be explored.