The Community-Centered Health Homes Model: Updates and Learnings



Detailed Description

A publication providing a framework to address community conditions that impact health as well as lessons learned from health care organizations that have implemented the Community-Centered Health Homes (CCHH) model. The Community-Centered Health Homes model, first presented by Prevention Institute in 2011, provides a concrete framework for healthcare organizations to systematically address the community conditions that impact their patients. It combines years of prevention experience about how to keep people from getting sick or injured, with insight gained from interviewing healthcare organizations around the country who were inspired to improve their patients' health and the health of the communities around them.

We are seeing a rapid transformation in healthcare delivery and there is tremendous pressure to provide high quality care while reducing costs and improving the health of individuals and communities. Momentum is building for healthcare organizations to contribute to advancing population health& the health of every resident in the geographic areas where they operate. Our latest brief reviews and analyzes what we've heard from clinics actively involved in community change & particularly clinics doing early testing of the CCHH model and summarizes what we've learned over the years. Through talking with healthcare providers, presenting the CCHH model to various audiences, analyzing how some healthcare providers are engaging in various elements, and synthesizing learnings from demonstration projects currently underway, we identify lessons learned and common themes that have emerged for healthcare organizations that want to implement the CCHH model. Produced by the Prevention Institute

Failing Forward Moments


Type of Tool

Tool or toolkit


community centered, Social Determinants, patient centered, experience

Key Contacts

Rea Panares, Leslie Mikkelsen, Roza Do


  • System change: Public health transformation

  • Health System Transformation Oasis

  • Health care (payers, service providers, device/pharma, IT/infrastructure)

  • Effective

  • Organization

  • Not Applicable

Geographic Context
  • Not applicable

Geographic Unit
  • Not applicable

  • Portfolio 3 (Improving community health and well-being together with partners for a specific issue)

    ​​​​In this portfolio, health care organizations work together with community partners to improve specific health and wellbeing outcomes for a place-based population.

Action Areas
  • Social determinants screening/referrals

    ​​​​​​Resources to help implement a type of internal assessment used by healthcare organizations to consistently screen for and address the social and spiritual drivers of health and wellbeing for a defined population, with a goal of ultimately connecting patients with community resources. Social drivers of population health include socioeconomic factors such as food, housing, education, transportation, and income, and social connectedness. Spiritual drivers include all factors that contribute to a sense of purpose, meaning, self-worth, hope, and resilience.

Words to Describe