Sustainability Resources

This page features resources and reference material for community agencies seeking to expand their service delivery models. 

  • How Health Care and Community-Based Human Services Organizations Are Partnering for Better Health Outcomes
    Partnerships between health care organizations and community-based providers address both social and clinical determinants of health.  These partnerships work together towards achieving the quadruple aim of health care.  Current delivery and payment models supports the development of health care organization and community-based provider partnerships.

  • Why Big Health Systems Are Investing in Community Health
    Changes in health care financing necessitates health systems to address the social indicators that impact patients’ ability to self-manage.  Kaiser Permanente Southern California are addressing social indicators by partnering with Health Leads, a national nonprofit that places volunteers in strategic areas of the health care delivery system.  ProMedica in northwest Ohio and southeast Michigan are setting up food “pharmacies” that provide food and nutrition counseling to address effects of hunger and poor nutrition for low-income patients. 

  • The Community Cure for Health Care
    Large health care systems are beginning to invest core operating dollars in connecting their patients to community resources, in service of the ultimate solution to better costs and outcomes: keeping patients healthy.

  • Multi-Sector Partnerships Have the Potential To Transform Health, But Most Aren’t There Yet
    Multi-sector partnerships develop more quickly and efficiently when the conditions are in place to catalyze their progress. The expectations for them are tremendous and partnerships can achieve sustainable change with game-changing interventions around stewardship, strategy, and financing.  It is important to design, test, and spread those interventions so that “how” to move forward is clear enabling strategic partnerships.

  • Defining the Health Care System’s Role In Addressing Social Determinants And Population Health
    It is now widely recognized that the health outcomes of populations often are determined more by social factor than by medical care. Two models serve as useful points in discussions of how population health activities are orchestrated.  Both take the form of a hub-and-spoke, where the hub allocates funding to and coordinates activities of spokes.  The first model positions a health care organization at the center of the model and imagines other community-based organizations as spokes. In the second model, health care organizations would take on the role of a spoke alongside a range of other community actors, leaving another organization to take up the hub position.

  • Health Care That Targets Unmet Social Needs
    Kaiser Permanente (KP) launched its Total Health Initiative in 2014 to promote healthy eating and active living among its members, it has now begun to bolster that effort by aiming to target members’ unmet social service needs as part of their overall health care. Social, environmental, and behavioral factors account for an estimated (PDF) 60% of health.  A call center contacts a patient ad screens them with a series of questions to determine where they need additional support services to address their unmet needs.  Over 70% of respondents have been linked and connected to Kaiser Permanente Total Health initiative to address unmet social needs. 

  • Integrating Medical and Social Services: A Pressing Priority For Health Systems And Payers
    report (PDF) supported by the Blue Cross Blue Shield of Massachusetts Foundation shows there is solid evidence that increased investment in selected social services, and improved coordination between medical and nonmedical services, can improve health outcomes and lower health care costs for certain populations. The Commonwealth Fund’sHealth Care Delivery System Reform program has outlined criteria to help guide their selection of projects. Thirteen projects since 2014 have been funded.

  • Cross-Sector Partnerships to Address Health-Related Social Needs
    Communities nationwide have been forming partnerships between healthcare providers and community-based organizations to enhance health-related social needs. Researchers from The Commonwealth Fund highlighted common challenges and proposed solutions for these partnerships.

  • Partnering with Community-Based Organizations for More Broad-based Public Engagement
    Publication that reviews the benefits of partnering, selecting partners, types of partnerships, the conditions that support effective collaboration, and outlines common challenges that occur with community partnerships and how to avoid them. 

  • Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians
    The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services provides educational materials to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse. (Download PDF)

  • Compliance Program Guidance for Medicare+Choice Organizations
    OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements. (Download PDF)

  • Summary of the HIPAA Privacy Rule
    This is a summary of key elements of the Privacy Rule including who is covered, what information is protected, and how protected health information can be used and disclosed.  From HHS. (Download PDF)

  • Sample Auditing Compliance Plan (PDF)
    Sample document outlining components of an auditing compliance plan.

  • All About OSHA
    Background materials on the Occupational Safety and Health Administration. (Download PDF)

  • Clinical Laboratory Improvement Amendments (CLIA)
    The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations include federal standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. CDC, in partnership with CMS and FDA, supports the CLIA program and clinical laboratory quality. (Download PDF)

  • Teaching CBOs to Develop Business Strategies
    For community-based organizations (CBO) and the health care sector, the passage of the Affordable Care Act created new opportunities by shifting the focus from fee-for-service to fee-for-outcomes.  To maximize these opportunities, CBOs need to develop business strategies that leverage their strengths.  Aligning core competencies, focusing on areas for improvement, and being willing to evolve within the environment can not only sustain organizations, but also allow them to thrive. 

  • W.K. Kellogg Foundation Logic Model Development Guide
    Logic models can help programs evaluate the effectiveness of their program activities.  This guide provides practical assistance to nonprofits.  Stakeholders will find the underlying principles of “logic modeling” to enhance their program planning, implementation, and dissemination activities.  

  • Return on Investment (ROI) Calculator
    This calculator is designed to assist community-based organizations and their medical partners in creating mutually beneficial financial arrangements for funding the delivery of social and supportive services.  This financial tool will calculate the return on investment (ROI) from integrating social services with medical care.  The calculator will compare how the financial returns and risks could be divided between the cross-sectional partners (social service and medical) under a variety of payment arrangements and levels.

  • Marketing Strategy and Competitive Analysis
    This online course consists of four distinct segments. Covered topics include determining which customers your organization should serve and selecting the most appropriate customer targets, identifying and measuring customers’ needs and wants and which products and services to offer them, and developing marketing programs.

  • How to Make a Business Case
    This course, which consists of five distinct segments, provides the methods for making a convincing business case. Covered topics include justifying expenditures and demonstrating significant economic benefits for business partners. The course also describes common pitfalls and offers various hints to conduct business cases accurately and convincingly.

  • How to Price Long Term Services and Support
    This course, which consists of five distinct segments, provides the rigorous yet practical approaches to pricing long-term services and support. CBOs that have traditionally provided long-term services and support on a grant or philanthropic basis, can now sell these services to health plans, hospitals and other parties in the medical sector. This course teaches profitable commercial pricing strategies, while recognizing the nuances and complexities of the health sector.

  • Project Planning and Management
    This course, which consists of five distinct segments, provides a practical and simple framework for conceiving, designing, and implementing the types of projects and that CBOs commonly undertake. Systematically, this framework leads to the identification of projects that are the most urgent to address and the most likely to succeed. Covered topics include problem identification, articulating goals and measurable objectives, and identifying individual tasks that must be executed in order to complete the project.

  • Strategies for Sustainability
    What happens when project funding ends? Sustainability is the continuation of a project’s goals, principles, and efforts to achieve desired outcomes. This fact sheet shares valuable lessons learned from AIDS United's Access to Care initiative grantees from their own experiences sustaining projects after funding ended.  

  • Practice Management Toolkit Financial Key Performance Indicators
    This toolkit from the American College of Physicians contains a series of spreadsheets intended to give the owner physician or office manager templates for monitoring key financial indicators within the practice. 

  • National Correct Coding Initiative (NCCI) Tool
    The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. This site has downloadable tools and instructions for Medicare providers. (Download PDF)