Linking Health Plans to CBOs - Filling Gaps and Addressing Health Equity Barriers

Linking Health Plans to CBOs – Filling Gaps and Addressing Health Equity Barriers

In Their Shoes: Linking Individuals to CBOs

Health disparities surround iconic figure to include: Money, health care professionals, transportation, housing, and utilities.Let’s put ourselves in the shoes of an elderly, low-income New York City resident with heart failure and diabetes. We will call them “Brooklyn.” Brooklyn has no transportation or support and cannot afford nutritional meals. Brooklyn can barely afford to pay rent and is at risk of having her electricity cut off this month. On top of this, Brooklyn’s healthcare team is having trouble managing her heart failure and diabetes. As a result, she ends up in the emergency room (ER) with high blood sugar and is in fluid overload multiple times a month. Unfortunately, Brooklyn’s situation is not uncommon in our healthcare system.

Who helps prevent this? Who steps in? Where can Brooklyn turn? It takes a collaborative effort with community-based organizations (CBOs) to get the help patients need. When an individual faces a barrier to living a quality life, a CBO steps in to provide services and help break down the barriers.

CBO Explained

What is a CBO, and what role does a CBO play? The definition varies depending on the work the CBO does within the community. Some are specialized with tailored programs for specific populations, while others are more general resource providers for the community. The U.S. Department of Health and Human Services (HHS) defines a community-based organization as “public or private not-for-profit resource hubs that provide specific services to the community or targeted population within the community.”1

In 2004, the University of Michigan School of Public Health, in coordination with the American Public Health Association, defined a CBO as an organization “that is driven by community residents in all aspects of its existence. [meaning] the majority of the governing body and staff consists of residents, [their] operating offices are in the community, priority issue areas are identified and defined by residents, solutions to address priority issues are developed with residents, and program design, implementation, [as well as] evaluation components have residents intimately involved, in leadership positions.”2 A CBO’s community relationships have a tremendous impact in the community because of the significant level of rapport they have. The role of a CBO is unmatched as CBOs hold a unique understanding of what barriers impact the health of the population they serve at the individual and community level.

Read the full study of CBOs here:

CBOs, Addressing Health Disparities on the Ground

CBOs are often the first door community members walk through to obtain access to resources and solve or prevent complex social barriers, which is why they are one of the first referrals healthcare workers and local agencies make when a patient, like Brooklyn, facing complex barriers is identified. CBOs are on the ground in the community, going door to door to assess and address social barriers. In this case, Brooklyn is facing financial barriers impacting her ability to manage her health. She needs help getting medications, transportation, nutritious meals, keeping the electricity on, and emotional support. This triggers when referrals are made to CBOs.

In New York City, Brooklyn started working with God’s Love We Deliver (GLWD), a CBO that delivers quality meals designed by registered dieticians to meet customers’ medical needs. GLWD then directed her to another CBO, helpNYC. Brooklyn met with a local care navigator to evaluate her social determinants of health and address all Brooklyn’s other needs.

Now, Brooklyn is receiving meals at home built specifically for her health needs. In addition, the care navigator was able to help Brooklyn access transportation so she no longer misses medical appointments. Brooklyn’s medication is now delivered to her home, and she is no longer having issues paying for the energy bill thanks to getting into the Home Energy Assistance program.

These changes result in Brooklyn having better management of her heart failure and diabetes, and she is able to enjoy a better quality of life. The ER now sees much less of Brooklyn, and Brooklyn has been connected to support for the first time in a long time. This example highlights the difference CBOs can make for individuals and communities—but CBOs face their own challenges as well.

The Door is Open for CBOs and Health Plans

While the importance of linking the CBO has gained traction since introducing the Value-Based Reimbursement system (see Dr. Adrienne Mims’ blog, “Why move from Fee-for-Service to a Value-Based Reimbursement System? To learn about VBR”).3 CBOs still face the challenge of getting a seat at the table in the healthcare industry regardless of their proven ability to improve patient outcomes, reduce total cost of care, and reduce hospital utilization.

As discussed during the “Clinical Community Linkage” session at the NCQA Health Innovation Summit ( this year in Washington D.C., challenges CBOs face include stigma, funding, policy, and not being viewed as a contributor to research or development.

The COVID-19 Pandemic has opened the door to the healthcare industry for CBOs, health plans, and providers to work together collaboratively with a sense of urgency. The significance of having on the ground in the community resources has proven to be a key component to improve health outcomes. The Administration for Strategic Preparedness and Response states “As trusted entities within their communities, CBOs are well positioned to partner with emergency management and public health entities to address the access and functional needs of at-risk individuals during future public health emergencies.4

Collective Impact in a circle in the center of a pentagon. The 5 sections of the pentagon are: 1) A common agenda for change 2) Shared measurement for data & results 3) Mutually reinforcing activities 4) Open and continuous communications 5) A 'backbone' coordinating organisation/sWith the movement across healthcare organizations to center their focus around health equity, there are great opportunities to generate integrated partnerships with CBOs on a national level. At the NCQA summit, Kitty Bailey, CEO of San Diego Wellness Initiative, discussed the path for CBOs to move forward with health plans, which will take a reevaluation of business process, system thinking, and a lot of teamwork. “This is about going beyond data, we need to recognize the need for community work, break the Managed Care Organizations way of business, and obtain a true collaborative relationship between CBOs and health plans using a collective impact model.” (NCQA Conference)5

Some states have begun their initiatives to reduce health disparities through the linkage of CBOs. California has had various successful partnerships with CBOs, shedding light on the way forward, linking CBOs and health plans, generating a blueprint to their success. (see In 2021, Pennsylvania started work on this initiative, creating contractual relationships that allow CBOs to receive payment for their services as vendors. ( These linkages are great efforts towards creating a more equitable healthcare system.

Going Beyond Data

By linking CBOs to health plans and improving patient outcomes, it’s important to remember the goal is reducing disparities and achieving an equitable healthcare system. Let’s take a look back Brooklyn. The emergency room Brooklyn frequented made two CBO referrals—helpNYC and GLWD—that were then able to step in and address all barriers, reducing Brooklyn’s ER visits. This clinical-community linkage generated tremendous impact on Brooklyn’s quality of life and hospital utilization.

CBOs provide immeasurable value to reducing health disparities and impacting communities. Do they reduce the total cost of care? Yes, but this is about more than that.

Brooklyn is our neighbor, parent, sibling, friend. If we take the steps for our healthcare system to invest in CBOs, we invest in our community. CBOs have proven their ability to increase quality of health and just how significant their role is in the healthcare system. With the long-time coming shift in focus to health equity, the doors are open to make long-lasting clinical community linkages.

Questions for the reader:

How has a CBO had an impact on your life?

What is the way forward integrating CBOs in the healthcare system?

How do we generate long-lasting clinical community linkages?

  1. Engaging community-based organizations. ASPR. (n.d.). Retrieved December 7, 2022, from

  2. What is a CBO?: National Community–Based Organization Network (NCBON): University of Michigan School of Public Health. National Community–Based Organization Network (NCBON) | University of Michigan School of Public Health. (n.d.). Retrieved December 7, 2022, from

  3. Mims, Adrienne M.D. “An Unlikely Provider to Improve Maternal Health Outcomes and Reduce Disparities: Pharmacists.” Rainmakers Strategic Solutions, LLC. October 2022,

  4. Improving the Integration of CBOs: Building Relationships in Preparation for the Next Emergency. United States Department of Health and Human Services (n.d.). Retrieved December 7, 2022, from

  5. Bailey, K. “K., Buckley, B., Walters, D., & Wongvipat Kalev, N. (n.d.). NCQA Summit 2022. In Clinical-Community Linkages.

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