Contexture, Arizona’s health information exchange (HIE), teamed up with the Arizona Health Care Cost Containment System (AHCCCS) — and in collaboration with 2-1-1 Arizona and Solari Crisis & Human Services — to implement a single, statewide referral system (CommunityCares) to address social determinants of health (SDOH) needs in Arizona.

Our Mission

To streamline access to vital services through a closed-loop referral process that provides confirmation when social services are delivered.

Program Genesis

AHCCCS, Arizona’s state Medicaid agency, launched its Whole Person Care Initiative (WPCI) to focus on the social factors that have an impact on individual health and well-being, such as housing, employment, criminal justice, non-emergency transportation and home and community-based services interventions.

Whole Person Care Initiative

SDOH research suggests that social risk factors, behaviors and physical environment contribute 80% to an individual’s overall health while access to quality healthcare only contributes 20%.

Program Goals

  • Coordinating Care

  • Connecting communities

  • Improving health with a whole-person care mindset

  • Leading with a data-driven approach

CommunityCares System Features

  • Closed-loop referrals with outcome tracking

  • No wrong door — easily connect clients to resources in one platform

  • Screenings and assessments for identifying client needs

  • Alerts and communications about client case progress

  • Data dashboards, analytics and outcomes

  • Resource directory

The Journey Thus Far…

Advantages for Community-Based Organizations

As organizations aimed at making desired improvements to a community’s social health, well-being and overall functioning, community-based organizations (CBOs) are instrumental in providing necessary services to support those in need. 

CommunityCares provides myriad benefits designed to enhance care coordination and, ultimately, help better meet the needs of the
organization and people it serves, such as:

  • Keep track of the people you’re helping 

  • Access a reliable and up-to-date resource directory

  • Customize which services you accept referrals for and when

  • Monitor communications about client case progress

  • View and pull data on your organization’s activity

CommunityCares CBO Incentive Program

New financial incentive program that allows CBOs to earn up to $17,000 for joining CommunityCares and meeting participation milestones.

Participation Milestones:

  • Milestone 1 – $1,000

    Sign CommunityCares Access Agreement.

  • Milestone 2: – $1,000

    Complete the Partner Registration Form/Sheet.

  • Milestone 3 – $2,000

    Go live on the CommunityCares SDOH system and opt-in to receive referrals for at least one (1) service.

  • Milestone 4 – $3,000

    Meet utilization metric: Maintain a Median Time to Acceptance Rate of < 4 days for 6 total months.

  • Milestone 5: $5,000

    Meet utilization metric: Maintain a Median Time to Acceptance Rate of < 4 days for 12 total months.

*Food and Housing organizations are eligible for alternative utilization metrics to send referrals using CommunityCares.

Questions About CommunityCares?

Questions About CommunityCares?

Contact the CommunityCares team at

Visit the Unite Us website to find our CommunityCares Arizona page and all of our upcoming events.

For more information about our brand guidelines, please download the CommunityCares Visual Style Guide.

Program Partners