NCOA’s Roadmap to Community Integrated Health Care

The National Council on Aging’s (NCOA) Center for Healthy Aging is honored to serve as a partner with n4a’s Aging & Disability Business Institute (Business Institute) and contribute the important work of assisting community-based organizations (CBOs) to successfully adapt to a changing health care environment, enhance their organizational capacity and capitalize on emerging opportunities to diversify funding.

NCOA recognizes the immense value of CBOs and health care entities working together, and know that we can better support the creation and long-term success of these partnerships through collaborative efforts such as the Business Institute. Coordination of activities around CBO business acumen produces a robust, enduring collection of resources to support CBOs, whether the CBO is a novice just embarking on the journey of culture change for integration with health care or a Trailblazer CBO with extensive experience and multiple contracts with health care partners.

Through funding from the Administration for Community Living (ACL), the Center for Healthy Aging houses the National Chronic Disease Self-Management Education (CDMSE) Resource Center and the National Falls Prevention Resource Center. Both Centers function to serve local, state and national organizations seeking to implement and sustain evidence-based health promotion and disease prevention programs. A primary focus of our work is to assist ACL CDSME and falls prevention grantees and other CBOs to embed programs into an integrated, sustainable evidence-based prevention program network via centralized, coordinated processes.

In an effort to support CBOs efforts to partner with health care entities, the Resource Centers created the Roadmap to Community Integrated Health Care (CIHC). This Roadmap was designed to help aging, public health and disability professionals make stronger linkages with the health care sector to achieve better health through better care with CDSME, falls prevention and other evidence-based programs. It provides an interactive journey with various routes that one can choose to arrive at the destination of community-integrated health care.

The Roadmap provides information and resources related to NCOA’s CIHC Leadership Team and public policy and advocacy efforts. It also highlights NCOA’s two Learning Collaboratives, one focused on Network Development and another focused on Medicare Reimbursement for Chronic Disease Self-Management Education (CDSME) Programs.

The most robust portion of the Roadmap is referred to as the CIHC Toolkit which provides in-depth information about a variety of partnership possibilities, program delivery and evaluation methods and payment and reimbursement options. Each section not only includes detailed information on each topic, but also includes a ‘See It in Action’ section, in which a CBO who fits that partnership model is a featured success story. For example, the Accountable Care Organization (ACO) section of the Toolkit hosts useful information about ACOs and Accountable Health Care Community models, as well as invaluable insight into Southern Maine Agency on Aging and MaineHealth’s fruitful alliance. Other success stories focus on CBO partnerships with Federally Qualified Health Centers and hospitals. A video entitled, “Improving Quality of Life and Health Care Outcomes Through CDSME Programs” and Companion Guide was also developed to support CBOs conversations with potential health care partners.

The CIHC Leadership Team consists of experts who provide direction and guidance regarding NCOA’s business acumen work. They continually strengthen the Toolkit through the collection of best practices, technical assistance and interviews with experienced CBOs.

We encourage you to explore the Toolkit. Should you identify a gap in information within the Toolkit and/or be willing to share your experiences to support community-integrated health care, please contact Marissa Whitehouse at

We look forward to the ongoing enhancement of the Roadmap, which we feel is a complimentary resource to the Business Institute’s collection of business acumen tools.