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Connecting Health and Social Support

Strengthening dignity, equity, and quality of life through collaborative, community-centered care.

What is a Community Care Hub?

A community care hub brings together traditional healthcare and community-based organizations to coordinate support for service recipients in a seamless system. By streamlining referrals, collaboration, and payment for services, our community care hub makes it easier for people to access the right services and helps our partners work together more efficiently.

About SWCCP

Everyone deserves supportive, lasting health.

Southwest Community Care Partners (SWCCP) is a community care hub connecting healthcare and community support systems across the Southwest. Supported by USAging and the Administration for Community Living, we work with payors, providers, and human service providers to improve access, coordination, and long-term health outcomes.

Our Mission

We enhance the dignity and quality of life for people in the Southwest through a strong health-related social care network that fosters equity, collaboration, and community-centered services.

Gaps in The Current Healthcare System

Today’s healthcare and community organizations often operate in a fragmented system, leaving many health-related social needs unmet. According to public health research, these health-related social needs play a significant role in our ability to avoid comorbidities and manage chronic conditions.

Our fragmented healthcare system does not adequately address these factors, creating strain that makes care more costly and less effective for healthcare payors, healthcare providers, community-based human service provider organizations, and the people they serve.

How We Help

Healthcare Payors

We manage contracting and administrative work for healthcare providers and human service providers to reduce the overall cost per service recipient.

Healthcare Providers

We manage the referral process to human service providers, helping health providers remain focused on quality biomedical care.

Human Service Providers

We manage the referral process to reduce administrative burden and provide a better continuity of care.

Service Recipients

We connect service recipients with actionable, personalized support and services that support lasting health.

One Streamlined Process

Provider Identifies a Social Need

Provider Sends One Referral to SWCCP

Build a Personalized Service Plan

Our Human Service Provider Network Delivers Services

Payment and Outcome Tracking for Human Service Providers and Health Providers

What Sets Us Apart

We connect organizations to a unified, efficient referral network.
We reduce financial and administrative burdens so partners can focus on service.
We support a stronger, more equitable system that benefits everyone involved.
We are proud to work with dedicated partners who help us support our community at the highest standard.

We Partner With Organizations Who Connect People To

Housing & Shelter

Food Assistance

Transportation Assistance

Evidence-Based Health Promotion

Care Transitions

Dementia Services

Partner With Us

Donate

Success Stories

Ohio

Direction Home Akron Canton Area Agency on Aging & Disabilities (DHAD)

DHAD serves as Ohio’s Community Care Hub, coordinating a statewide network of 12 Area Agencies on Aging to deliver transitional care services for Medical Mutual of Ohio members. Formed to address the need for better post-hospital support across Ohio’s 88 counties, DHAD provides registered nurse home visits, medication reconciliation, and connections to community resources within days of hospital discharge.

Results demonstrate value across the care continuum:

For Members:

Over 3,100 served annually with a 30-day readmission rate of 8.2% − well below national averages − and 93% satisfaction.

For Human Service Providers:

Standardized workflows, shared resources, and workforce flexibility across sites enable consistent, quality service delivery.

For Healthcare Payors:

Medical Mutual of Ohio achieved a 5-star CMS rating, crediting this partnership as a key factor.

For Healthcare Providers:

DHAD participates in Grand Rounds for complex cases, functioning as an integral extension of the clinical team while reducing costly readmissions.

Maryland

Maryland Living Well Center of Excellence (LWCE)

LWCE, a division of MAC Inc. Area Agency on Aging, serves as Maryland’s Community Care Hub for evidence-based health promotion programs across the state. Established in 2015 in response to Maryland’s Total Cost of Care Initiative, LWCE partners with TidalHealth and other health systems to provide chronic disease management, falls prevention, and depression reduction programs alongside wrap-around services like meals and transportation.

The partnership delivers measurable impact:

For Members:

2,542 older adults served since 2015, with strong reach to underserved populations (49% Black, 14% Hispanic, 3% Asian).

For Human Service Providers:

Direct access to Maryland’s Health Information Exchange enables seamless referrals and outcome tracking.

For Healthcare Payors:

$564,868 in healthcare cost savings from just two programs in 2021, with reduced hospital stays, readmissions, and ED visits.

For Healthcare Providers:

TidalHealth physicians now routinely refer high-risk patients; the model expanded to Johns Hopkins, MedStar, and the University of Maryland Medical System.

Six-State Region

New England Evidence-Based Program (EBP) Network

Led by AgeSpan’s Healthy Living Center of Excellence in Massachusetts, this pioneering multi-state network connects six state hubs across New England to deliver evidence-based health programs. Created in 2020 to address the region’s aging population − nearly 20% are 65 and over − and consolidating healthcare markets, the network enables coordinated program delivery across state boundaries while maintaining local community connections.

Regional collaboration expands reach and efficiency:

For Members:

Over 5,000 older adults annually access over 15 evidence-based programs, including non-English language options, advancing health equity.

For Human Service Providers:

Over 70 partners share program leaders, trainers, and resources across state lines; a rapid COVID pivot enabled remote delivery to vulnerable populations.

For Healthcare Payors:

Streamlined contracting with a single regional entity rather than separate negotiations in each state.

For Regional Payers:

Particularly valuable for insurers like Point32 Health (2.4 million members across five states) seeking unified approaches across expanding footprints.

Virginia and Pennsylvania

Peninsula Agency on Aging (PAA) and Bucks County Area Agency on Aging (BCAAA)

Through USAging’s pilot program, PAA in Virginia and BCAAA in Pennsylvania partnered with health insurers HealthKeepers Inc. and AmeriHealth Caritas to provide benefits counseling and enrollment assistance. The initiative addressed a critical gap: over $30 billion in public benefits go unclaimed annually by eligible older adults due to a lack of awareness, perceived complexity, and uncertainty about where to apply.

Targeted outreach produces meaningful connections:

For Members:

PAA assisted 122 health plan members (20% of those contacted); 66% of those were connected to lesser-known state and local benefits beyond traditional programs.