A definition
A Social Care Network is a formal coalition of organizations — health plans, hospitals and providers, government agencies, and community-based organizations (CBOs) — that coordinates around health-related social needs (HRSN) for a shared population. In Medicaid contexts these networks are often organized as Community Care Hubs, Medicaid Lead Entities, or Accountable Communities for Health.
Unlike a single referral tool or resource directory, a Social Care Network is an operating model: it has member intake and eligibility processes, a contracted network of participating CBOs, shared financing and authorization rules, and accountability for outcomes across every organization in the network — not just the lead agency.
Why Social Care Networks exist
Health-related social needs — housing instability, food insecurity, transportation barriers, utility assistance, behavioral health access — routinely drive avoidable health care utilization. No single organization can address all of them. A Social Care Network exists to connect the health system, government funders, and the community organizations that actually deliver food, housing, and transportation services into one coordinated structure, so a member's needs move through a managed pathway instead of a maze of disconnected referrals.
How Social Care Networks operate
Most networks share a common operating pattern: a lead entity holds contracts and funding, a network of credentialed CBOs delivers services, and a shared technology layer routes referrals, tracks capacity, and reports outcomes back to funders and health plans. Core operational functions typically include network adequacy management (do we have enough capacity for the needs we're seeing), closed-loop referral tracking (did the need actually get resolved), financial operations (authorizations, encumbrances, invoicing across dozens of contracted CBOs), and outcome reporting for regulators and payers.
Technology requirements for a Social Care Network
Because a Social Care Network spans many independent organizations, its technology has to work across organizational boundaries — not just inside one agency. That typically requires: a closed-loop referral system usable by CBOs with limited technical capacity, real-time visibility into partner capacity and network adequacy, financial tracking for authorizations and obligations across the network, population-level intelligence to identify emerging need and service gaps, and interoperability with clinical systems (FHIR, HL7, eligibility feeds) so social and clinical data can inform the same care decisions.
How Relay Helps
Relay is built specifically to operate a Social Care Network — not just to route referrals inside one organization. The platform combines closed-loop referral management, provider network operations, financial operations (authorizations, encumbrances, and obligations across a contracted CBO network), and population intelligence in one system, so a Medicaid Lead Entity, Community Care Hub, or Accountable Community for Health can run the network from a single operating layer instead of stitching together spreadsheets and point tools.