Achieving Health Equity: Community-Led Alternatives to Healthcare-CBO Partnerships

NFF has engaged in numerous efforts across the country focused on facilitating partnerships between community-based organization (CBOs) and health care providers and payors (HCOs). When entering these partnerships, both CBOs and HCOs express an intent to address the social determinants of health (SDOH), improve health outcomes, and increase health equity.

However, despite the tremendous time and resources that both CBOs and HCOs pour into these partnerships, NFF’s work on the ground shows us that the impact doesn't match up. CBOs and HCOs continue to enter this work with vastly divergent goals. Even when the partnerships are successful, they rarely improve health equity. Sometimes, they even harm the individuals and the communities the partnerships are intended to serve.

While we applaud the spirit of the effort that initially led to this pursuit, we no longer believe that CBO-HCO partnerships represent a path to the systems change needed to achieve true health equity. In this blog, we share the lessons we've learned from our role in these partnerships – and propose community-led alternatives that we believe represent a better solution.

Despite years of work to advance SDOH, HCOs and CBOs address SDOH in vastly different ways. In our experience, many CBOs prioritize issues like safe housing and neighborhoods, nutritious food, and economic stability in their definition of SDOH. As such, demand for their services often exceeds their ability to provide what their clients need, so they seek partnership for help in addressing these issues. HCOs generally take a narrower approach, focusing on addressing SDOH primarily by enhancing individual access – either by helping patients to access the clinical services they provide or by making smooth referrals to services provided by other community stakeholders.

Unsurprisingly, because HCOs almost always have more resources – and more power – than their CBO counterparts, the resulting contracts prioritize access and referrals over supporting the services themselves. As most CBOs’ funders do not cover the full cost of providing services, it is up to the CBO to find funding to cover the cost of providing more services for these referrals – which can undermine the CBO’s ability to operate.

In addition, we have observed that HCOs are typically concerned with targeting the limited number of individuals or patients that they serve directly. Often, they seek to address the specific needs of those individuals for whom an intervention is likely to result in a demonstrable cost savings, particularly within the time frame of less than a year. For example, even when there is alignment between a CBO and HCO on the importance of nutritious food, HCOs are often only interested in paying for medically tailored meals for a specific individual when it is likely that their entire family is food insecure.  

Again, given the differential power of CBOs and HCOs, many contract deliberations center on addressing short term needs with quantifiable outcomes. Because CBOs rarely view their work this way, they end up having to alter their service delivery model or their impact evaluation strategies to engage in these partnerships – a significant investment of time and resources that might be better spent elsewhere.

These ingrained differences between HCOs and CBOs draw out contract negotiations and diminish the impact of the partnerships that result. Resources that CBOs could use to provide critical services instead go to legal fees, new compliance requirements, and customized data systems to support programs that only serve a small portion of their clients. This directly harms both CBOs and the communities they serve.

In addition, HCOs tend to seek out interventions with a deep evidence base – and those organizations with the means to offer evidence-based interventions. This approach disadvantages many CBOs – particularly those that are newer, those that have historically been shut out of financial investments that would enable them to generate the needed evidence, and those led by people of color who may not have had the same access to institutional hallways of power and influence as their white counterparts. Centering highly resourced, white-led organizations doesn't promote health equity – it perpetuates the racial disparities that currently exist.

Partnerships between CBOs and HCOs are still perceived as the gold standard for achieving health equity. As a result, communities and organizations are investing substantial resources into these partnerships – with little to show for it.

HCOs consistently cite the political landscape – not their own approach – as the main barrier to equitable and meaningful partnerships. If they continue to point to policy-based issues – like being beholden to services that are Medicaid billable instead of acknowledging their own role in deprioritizing the needs of communities – the pace of change will remain maddeningly slow.

To truly address the social determinants of health and achieve health equity, we need to start in a very different place. Without an intentional effort to reimagine the health care system, we will not achieve even our most modest health equity goals. This re-imagining needs to be led by communities that name their own priorities and their own processes to achieve them.  

NFF client Thomas Jefferson Area Coalition for the Homeless (TJACH) is an example of how this can work. This network of community members – including CBO leaders, local health department employees, students, formerly unhoused residents, and many others – in Charlottesville, Virginia pivoted away from contracting with healthcare to a community-led effort to end homelessness that intentionally centers equity in the process. Rather than relying on partnerships with HCOs to provide their services, they are building on their abundant and ready assets of people, networks, and community-centered expertise.

We believe that new models of community-led healthcare need to receive the same “star” treatment that CBO-HCO partnerships have been given. With the proper investment, community-centered models of care can make measurable steps toward the equity they have long sought to achieve. 

Learn more about NFF's work at the intersection of health and outcomes, including what we've learned from the Advancing Resilience and Community Health (ARCH) project. For more insights on healthcare-CBO partnerships, read Perspectives from the ARCH Project: How do leaders from healthcare institutions view social determinants of health? authored by Jean-Baptiste and Alaya Martin of Mathematica with reflections from NFF.

And to learn more about how we’re centering community-led efforts to promote racial equity, visit our strategy page.

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