NCQA and Medical Home Network Announce Joint Project Funded by Robert Wood Johnson Foundation

  • Published On  May 10, 2018

FOR IMMEDIATE RELEASE                                           

May 10, 2018                                                              


NCQA and Medical Home Network Announce Joint Project Funded by Robert Wood Johnson Foundation 

Study will investigate most effective means for connecting medical care and social service needs

WASHINGTON, DC—The National Committee for Quality Assurance (NCQA) and Medical Home Network (MHN) are proud to announce a joint research project to study the effects of connections between patient-centered medical homes (PCMH) and community-based organizations (CBO). This grant is managed by the Systems for Action National Program Office with support from the Robert Wood Johnson Foundation.

Studies show people with social risk factors (e.g., homelessness, unemployment, food insecurity) can have healthier outcomes if their social service needs are resolved. Addressing social risk factors is challenging for medical homes as most do not have adequate mechanisms for referring patients to services. Additionally, most CBOs do not have electronic records and cannot easily communicate with medical home electronic health records. Issues of protected health information and privacy have also blocked progress in this area. 

Through this research, we will investigate the impact of connecting medical homes and CBOs using a web-based system. We hope to understand how those connections affect the use of hospital and emergency department services, and affect health outcomes of at-risk populations.

“We want to see how connecting medical and social service care teams can help people with social risks,” said Sarah Hudson Scholle, Vice President of Research & Analysis, NCQA. “For example, if the medical care team and social service agencies coordinate to help people with immediate problems (substance abuse, food, housing, jobs), will that help them manage their health needs better or keep them out of the hospital?”

NCQA, MHN and Cook County Health & Hospitals System (CCHHS) are partnering in this effort with medical homes and CBOs in Cook County, Illinois. As many as 200 medical homes and 25 hospitals will link to a variety of CBOs using a web-based communication and care management platform, known as MHNConnect.

This new connectivity between social service agencies and medical homes is the latest innovation in the network facilitated by MHN. It adds to a system that already connects 200 medical homes and 25 hospitals in Cook County, Illinois, serving one of the largest Medicaid managed care populations in the country.

“Economic opportunities, housing, legal resources and access to food- these social determinants all play a significant role in a person’s ability to get and stay healthy,” said Dr. Jay Shannon, CEO, CCHHS. “This project will help us understand where providers like Cook County Health can work more effectively with social service groups to improve our patients’ health status.”

MHN connects a community of healthcare providers, which enables enhanced care coordination using better workflows and bidirectional communication between care teams and community agencies.

“Our care management process incorporates addressable medical, behavioral and social factors and promotes whole-person care. We are connecting in a way that enables meaningful conversations and collaborative care management between medical homes, health systems, health plans and the community agencies, which is critical to providing coordinated, patient centered care for those we serve,” said Cheryl Lulias, president and executive director, Medical Home Network.

If successful, the implementation project will foster further cross-sector collaboration to benefit the patient population’s health and well-being.



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About NCQA

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website ( contains information to help consumers, employers and others make more-informed health care choices. NCQA can be found online at, on Twitter @ncqa, on Facebook at and on LinkedIn at

About Medical Home Network

Medical Home Network is transforming health care delivery for Medicaid patients by fostering collaboration and innovation. Our proven model of care unites communities of providers and patients around a common goal: To redesign health care delivery and transform the way care is delivered and managed, resulting in improved patient care, lower costs and better health in the communities we serve. MHN can be found online at and on LinkedIn at


About Cook County Health & Hospitals System

One of the largest public health systems in the nation, the Cook County Health & Hospitals System (CCHHS) serves as the safety net for health care in Chicago and suburban Cook County. CCHHS is comprised of two hospitals, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan. The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCHHS is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, collaborative health plan and enhancing the patient experience.