What Is a Social ACO and How Does it Help Achieve Whole-Person Care?

Care Coordination

Accountable care organizations (ACOs) are forming all over the country as policymakers, health plans, and providers pursue care delivery and payment reforms in an effort to reduce health costs and improve patient outcomes. An ACO connects state Medicaid agencies, primary care, and community-based providers to deliver a fundamentally different way of delivering healthcare services. As currently structured, however, most ACOs still fall short of achieving whole-person care by not fully addressing the social determinants of health which affect an individual’s overall wellbeing. Enter the Social ACO.

Social ACOs serve populations with complex and often unmet social and economic needs that impact health outcomes and health system utilization, including needs related to housing, food security, and nutrition, legal assistance, employment support, and/or enrollment assistance. A successful Social ACO addresses these needs with a strong partnership between traditional healthcare delivery and social service organizations in the form of a financially integrated delivery system. Commonwealth Care Alliance in Massachusetts and Hennepin Health in Minnesota are two of the nation’s first Social ACOs.


Commonwealth Care Alliance of Massachusetts (CCA) is an early innovator in developing a social ACO approach. Over ten years ago, CCA developed a model to provide whole-person, community-based care to support individuals with chronic disease and disabilities who were also dual eligible for Medicare and Medicaid. CCA’s model is based on enhanced primary care and intensive case management, coordinated through a single person responsible for the patient’s care. The CCA Care Model also gives patients and their families an active voice in developing highly individualized care plans.

From the time of enrollment, members are encouraged to be active participants in their own care. CCA members receive a face-to-face comprehensive needs assessment to ensure an in-depth understanding of the member’s clinical, functional, nutritional, social, and long-term care requirements. Needs related to social supports are documented during the assessment and CCA then assembles an interdisciplinary care team that coordinates all aspects of the member’s care. In cases where multiple social service supports may be necessary, a health outreach worker may be assigned to help coordinate services such as housing, food security, and transportation. The care team revisits the comprehensive assessment at least every six months in order to review and make any necessary modifications to the member’s care plan.


Hennepin Health has also created an out-of-the-box Social ACO model that takes on additional risk by partnering with social service organizations to provide whole-person care for vulnerable individuals in the community. Their goal is to promote early intervention to provide better health and prevent patients from becoming “super-utilizers” who use a larger share of healthcare resources while still experiencing poor outcomes. Upon enrollment, Hennepin Health conducts an in-depth patient needs assessment and then assigns its highest risk patients to a “call me first” evaluator responsible for coordinating all social, behavioral, and economic services. Staff then use algorithms to analyze new members’ medical histories. Hennepin Health is also supplementing medical information with data from the corrections department, foster care system, housing providers, and other local agencies to identify those whose health may be at risk because of non-medical issues. This ultimately enables them to provide whole-person care and reduce the overall costs of care.


In order to effectively coordinate care across multiple systems, social ACOs have taken steps to improve communication and coordination between primary care providers and community-based social providers. Some of these steps include:

  • Developing and promoting tools and resources
  • Building care coordination into electronic data transmittal systems
  • Offering technical assistance to providers
  • Developing measurement models to monitor care results

As care coordination across multiple providers is far more complex than care coordination using a single provider, technology plays a key role in the ability of ACOs to achieve these communication and coordination goals, which in turn allows them to be successful as they work towards improving lives through whole person care.

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