Arizona’s Statewide Closed-Loop Referral System

AHCCCS has partnered with Contexture and Unite Us to provide CommunityCares, Arizona’s Statewide Closed-Loop Referral System.

What is CommunityCares?

CommunityCares is a free tool available to help AHCCCS health care providers and community-based organizations quickly and efficiently screen and refer members for Health-Related Social Needs, also known as Social Determinants of Health.

Health care providers can use any Health-Related Social Needs screening tool they would like, as long as it screens for homelessness/housing instability, food insecurity, transportation assistance, employment instability, utility assistance, interpersonal safety, justice/legal involvement, and social isolation/social support. Health care providers can use CommunityCares on the web for free or integrate it into their Electronic Health Record at an additional cost.

How does CommunityCares work?

graphic of how CommunityCares referrals work
  1. An AHCCCS member has a visit with their health care provider.
  2. The health care provider uses one of CommunityCares’ screening tools to ask the member questions to see if they have any Health-Related Social Needs.
  3. If the member reports having a Health-Related Social Need the health care provider uses CommunityCares to find a local community-based organization that can assist the member.
  4. The health care provider sends an electronic referral to the local community-based organization through CommunityCares and provides information about the organization to the member.
  5. The local community-based organization receives the referral and contacts the member to fulfill the referral request.
  6. Once the referral has been fulfilled, the local organization marks the referral as complete in CommunityCares.
  7. CommunityCares notifies the referring health care provider that the referral has been completed and the member received the help they needed.

Health care providers are also able to screen and refer members to organizations that do not use CommunityCares.

What are the benefits?

In addition to helping AHCCCS members address Health-Related Social Needs to improve their overall wellbeing, providers may be eligible to participate in AHCCCS’ Differential Adjusted Payment (DAP) Program and receive financial incentives for using the system. Community-based organizations are eligible to receive up to $15,000 in financial incentives.

Learn more about CommunityCares, including the system’s features, financial incentives available, and how to sign up.