Statewide Closed-Loop Referral System:

CommunityCares

As a primary component of the AHCCCS Whole Person Care Initiative (WPCI), AHCCCS and our strategic partners have developed strategies to support providers, health plans, and community-based organizations (CBOs) in addressing the social service needs, commonly referred to as the social determinants of health (SDOH), of all Arizonans. Contexture worked on WPCI organized focus groups and workgroups to evaluate partnerships and candidates for a statewide SDOH closed-loop referral system (CLRS).

In February 2021, Contexture announced it was partnering with AHCCCS and 2-1-1 Arizona to implement a statewide SDOH CLRS, branded as CommunityCares. Community Cares will enable health care and community service providers to connect on a single statewide technology platform to seamlessly improve and track the referral process between health care providers and social services. In addition to streamlining the referral process and confirming when social services are delivered, the CLRS will provide a statewide solution to facilitate screening for social risk factors.

CommunityCares integrates with existing electronic health record systems, patient and member portals, and care/case management systems ensuring referrals are part of the routine workflow for all types of users. CommunityCares features include:

  • Evidence-based personalization that automatically maps social needs to services with matching algorithms, and filters results by factors like COVID-19 operating status, location, language, documents needed, and eligibility requirements;
  • Data collection and validation of service data to provide critical resource information;
  • Referral management to ensure that referrals are shared, tracked, and coordinated;
  • Coordination of SDOH including needs ranging from food insecurity and substance use, to cancer support;
  • Functional workflows that are embedded and integrated into operating systems to provide ease-of-use into a primary platform;
  • Outcome data to measure success; and
  • Single sign-on to share demographics, screening responses, and activity data, which reduces duplication and ensures records are current.

To join or learn more about CommunityCares, visit the Contexture SDOH page.