The research team interviewed eleven care management staff from four geographically diverse health centers and five subject matter experts in health information technology, all drawn from OCHIN, a nonprofit that hosts a shared instance of the Epic EHR for more than 2,000 community health center clinics across 37 states, the largest such network in the country. In 2022, OCHIN activated Epic’s care management module, called Compass Rose, which is designed to support care coordination activities including the tracking of contextual drivers such as food, housing, and transportation insecurity. Yet at the time of the study, fewer than 10 percent of OCHIN member clinics had ever used the module to make and track referrals for these needs, a striking adoption gap that motivated the investigation.

Methodologically, the study was a formative evaluation informed by human-centered design principles, conducted between September 2023 and July 2024. The researchers used semi-structured interviews paired with a virtual “guided tour” technique, in which participants shared their screens and demonstrated how they actually navigated the EHR to document screening, make referrals, and follow up, using a dummy patient record. Transcripts were analyzed with a rapid qualitative analytic approach organized around the Integrated Technology Implementation Model, and the findings were distilled into a care manager journey map that traces each step of addressing contextual drivers, the tasks involved, and the barriers that surface at each one. Preliminary findings were shared back with participants to verify accuracy.

Step one of the journey, screening, is the system’s relative bright spot. Health centers screen for contextual needs at check-in, rooming, or care management enrollment, and results are captured in EHR flowsheets that support longitudinal tracking. Some centers have configured alerts that prompt any staff member opening a chart to screen, and shortcuts allow quick insertion of relevant text into notes. Once documented, social risk data appear as color-coded icons in the EHR’s patient summary and within the care management module itself, giving care managers a consolidated view. One care manager described the appeal plainly: everything from screenings to disease-specific questions is “all right there,” eliminating the need to hunt across the chart for information relevant to care planning.

Step two, making referrals, is where the machinery begins to grind. For internal referrals to social workers or community health workers, care managers can use EHR messaging and referral ordering. For external referrals to community-based organizations such as food pantries or transportation services, some centers use community resource referral systems like Findhelp or Unite Us, platforms increasingly integrated with EHRs to enable closed-loop communication with registered organizations. But adoption of these platforms is hampered by two major challenges the participants identified: the effort and cost required for both clinics and community organizations to establish the referral model, and the fact that many community-based organizations lack the technological infrastructure to engage in the required data exchange at all. Relationships, participants stressed, matter as much as software; one expert recounted how a center’s referrals went unaccepted because the organizations it wanted to reach had never been onboarded to the platform.

Documentation of referrals proved equally problematic. Most EHR tools as configured at the participating centers offer no discrete field for referral documentation outside a specific referral work queue, and that work queue demands extensive manual entry and is not linked to care management care plans. Within the care management module, care plans include only pre-set, general referral options that must be customized by hand, a task one care manager called a “huge slowdown” that is “very, very time-consuming.” Worse, care plans built inside the module do not propagate to other views of the chart, forcing care managers to re-enter the same information elsewhere so that other care team members can see it. As one staff member explained, the care plan exists only in the module and “doesn’t cross over into any other part” of the record, so visibility elsewhere requires duplicative documentation. The practical result is that much referral information ends up in free-text notes, where it cannot be systematically tracked.

Step three, tracking whether patients actually connected with services, exposes the deepest gaps. Community resource referral systems could in principle close the loop by letting community providers report service receipt back into the EHR, but their limited adoption leaves most centers without that capability. Only referrals routed through the standard EHR referral work queue can be followed longitudinally, and even then, the lack of integration with care management care plans means outcome dispositions must be re-entered in multiple locations. Referrals documented in care plans through free text or shortcuts were not reliably trackable at all. One staff member admitted that after years of doing this work, the center had no formal referral pathway to community partners and could barely “fathom how that would work” given the scale of capturing and closing referrals. Notably, the care management module contains a “tasking” dashboard feature that could support referral tracking, but care managers reported they rarely use it for this purpose simply because they never received adequate training on how.

The study’s authors argue that these barriers can be sorted into three categories: technical, organizational, and those requiring implementation support rather than tool redesign. On the technical side, structured data fields for referrals, care plans customized to each center’s specific programs and reimbursement requirements, and alignment with emerging documentation standards such as those promoted by the Gravity Project could make referral data visible, actionable, and reportable. On the organizational side, the findings highlight a structural tension: health centers are investing heavily in EHR tools and workflows, but the community organizations receiving referrals are often under-resourced to participate in electronic exchange. Without investment in the infrastructure and readiness of those partners, even well-designed platforms will be underused, a problem likely to be most acute in communities with the fewest available services. The authors suggest implementation strategies that include assessing community organization readiness, mapping feasible referral pathways, and building backup workflows when electronic exchange is not possible.

Implementation support emerges as the study’s central prescription. Participants described their training on the care management module as something they “learned as we went,” with comments like “there wasn’t much training available” and wishes for “a much better training program.” Experts confirmed that hands-on, step-by-step guidance with demonstration and practice is the single biggest lever for improving uptake, and that support must be ongoing, since staff reported questions persisting even one or two years after adopting the tools. Leadership backing, workflow redesign coaching, and site-specific configuration assessments before training begins round out the recommended support package. These findings will now feed directly into a cluster-randomized trial, registered on ClinicalTrials.gov, that will test implementation strategies aimed at helping care management teams adopt EHR-based tools for social care coordination, an effort the researchers describe as the first of its kind. The study’s limitations are acknowledged: a small sample, a single EHR system, and the absence of community organization perspectives, though the authors note that Epic’s dominance in health centers and the breadth of roles interviewed strengthen the findings’ relevance.

The broader significance is hard to overstate. Federal and state programs, from Medicare’s Chronic Care Management codes to California’s CalAIM Enhanced Care Management, increasingly require the screening of social needs and linkage to services, and value-based payment models tie reimbursement to that documentation. If the electronic backbone meant to support this work remains siloed and untracked, centers risk both missed interventions for vulnerable patients and unfulfillable reporting obligations. This evaluation offers a precise map of where the technology works, where it breaks, and what a coordinated fix would require: better configuration, shared visibility across teams, genuine two-way infrastructure with community partners, and sustained, hands-on support for the people asked to use it.

Subject of Research: Adoption of electronic health record-based care management technologies for addressing social needs in community health centers

Article Title: Community Health Center Adoption of Enabling Technologies to Address Contextual Drivers of Health for Care-Managed Patients: Formative Evaluation

Article References: Owens-Jasey, C., Gunn, R., Cook, N., Fein, H. L., Pisciotta, M., Fee, C., Larson, Z., Templeton, A., & Gold, R. (2026). Community Health Center Adoption of Enabling Technologies to Address Contextual Drivers of Health for Care-Managed Patients: Formative Evaluation. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10735-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10735-6

Keywords: community health centers, electronic health records, care management, social needs, care coordination, health information technology, referrals, implementation science, contextual drivers, social determinants of health, qualitative research, health informatics

The study draws on interviews with leaders, clinicians, and care coordinators from six of the seventeen Medicaid ACOs operating in Massachusetts between 2018 and 2024. MassHealth, the state’s Medicaid program, launched its first ACOs under a section 1115 waiver in 2018 and renewed and expanded the program under a second five-year waiver in 2023. This makes the Massachusetts experience the first qualitative assessment of how Medicaid ACO programs implemented maternal health initiatives across multiple waiver periods. It also builds on earlier quantitative work by several of the same researchers, which linked ACO participation to improvements in maternity care engagement and quality—though not yet in hard health outcomes—with effects that varied across different ACO models.

The central finding is deceptively simple: metrics matter. During the first waiver period, ACO contracts required only a single maternal health metric—timely prenatal care. The second waiver period dramatically expanded the requirements, adding a metric for timely postpartum visits and mandating postpartum depression screening. Those contractual obligations, the researchers found, prompted organizations to adapt existing programs or build entirely new ones. Study lead and corresponding author Dr. Shannon Ogden, now a postdoctoral research fellow at the Kaiser Permanente Division of Research who conducted the work as a graduate research assistant at Boston University, explained that instituting maternal health-related metrics at the organizational level does push ACOs and healthcare organizations to develop the programs needed to meet those metrics and to track patients’ engagement. Leaders she interviewed, however, also acknowledged remaining gaps, signaling that considerable work lies ahead even in a state often viewed as a policy leader.

The mechanics of that change are instructive for policymakers elsewhere. With the support of care coordination teams, ACO leaders and clinicians reported that they were able to engage pregnant patients in prenatal care sooner, track births as they occurred, and motivate attendance at postpartum visits once the metrics were introduced. The Massachusetts policy environment reinforced these efforts: alongside the expanded contract requirements, the Commonwealth extended Medicaid coverage from sixty days to twelve months after delivery and began covering doula services, a combination that widened the window during which vulnerable patients could receive supported care.

Yet the study is equally candid about the formidable challenges that surfaced, and it finds that these varied substantially depending on the type of ACO model. Primary care-led ACOs, which are not embedded within comprehensive health systems, especially struggled to track patients’ care delivered out of network and over time. System delays in identifying pregnancies complicated efforts to reach people early in gestation, when interventions matter most. The researchers argue that these implementation barriers—rather than any inherent flaw in the ACO concept—explain much of the unevenness in results, and they offer recommendations that Massachusetts and other states can use to overcome the obstacles in maternal healthcare delivery.

Some of the most vivid findings concern the ingenuity of frontline care coordinators. Senior author Dr. Lois McCloskey, clinical professor of community health sciences at Boston University School of Public Health, described how coordinators worked around the siloed nature of medical care, doggedly following new mothers after birth to ensure they attended their postpartum visits. Many ACOs met the second waiver’s requirements by tailoring programs originally designed for patients with complex chronic illness to the needs of mothers experiencing pregnancy and postpartum complications. But McCloskey also flagged a structural blind spot: contracts did not require the same intensity of follow-up beyond the immediate postpartum period of roughly six to ten weeks after birth. That gap is clinically consequential. It is precisely in the extended postpartum period, she noted, when mothers—especially those with complications—are juggling the most and are most likely to fall through the cracks, and it is when they are most at risk for severe morbidity. In fact, about one-third of maternal deaths occur in this extended postpartum window, and many of them are preventable.

Doula care emerged as another priority of the second waiver period, and the evidence base behind it is compelling: continuous support from a trained doula has been shown to build trust between patients and the healthcare system and to improve equity in maternal care, benefits that are especially relevant for the Black and Hispanic patients who bear the brunt of maternal mortality disparities. ACOs that had already established a doula program or an effective care coordination team were able to deliver this service, but others reported difficulty hiring enough doulas within MassHealth’s network to meet demand. The workforce bottleneck illustrates a recurring theme in the study: mandates can create the will to act, but supply-side capacity determines whether that will becomes care.

The ACOs also broadened their focus during the second waiver period to address patients’ social needs—stable housing, adequate food, reliable transportation, and affordable utilities—which the Centers for Medicare and Medicaid Services and a growing body of research identify as significant drivers of maternal health. Pregnant and postpartum patients were screened for eligibility to participate in FLEX Services, MassHealth’s program allowing ACOs and other healthcare organizations to partner with community organizations to meet these needs. Care coordinators reported barriers here as well, including a lack of provider awareness of the program and burdensome application processes, though the researchers note that Massachusetts’ subsequent expansion of the FLEX program after the study period ended may have eased some of these problems. As Dr. Ogden observed, this holistic orientation inherently supports maternal health: helping patients find housing, pay for food, secure a job, or keep the electricity on can reduce the risk of poor outcomes before, during, and after pregnancy.

The study’s recommendations follow directly from its evidence. The research team urges states and healthcare systems to expand maternal healthcare performance metrics and patient tracking beyond the immediate postpartum period, and to invest in the innovations needed to strengthen care coordination and integration for pregnant and postpartum people. Sustainable change, as McCloskey emphasized, requires more than metrics; it requires sufficient, tangible resources to make change meaningful. The work was coauthored by researchers at W2 Consulting Corporation, Harvard Medical School and the Harvard Pilgrim Health Care Institute, and Boston University Chobanian and Avedisian School of Medicine, and forms part of a larger research program led by Dr. Megan Cole of Harvard Medical School, funded by a $3.8 million grant from the National Institute on Minority Health and Health Disparities. If states heed the lessons from Massachusetts, the researchers argue, strategic direction and investment of this kind could contribute meaningfully to reversing the alarming maternal morbidity and mortality rates that persist in the United States—and that continue to burden Black and brown communities most of all.

Subject of Research: How Medicaid Accountable Care Organizations implement maternal health initiatives to improve care quality and equity

Article Title: How Medicaid ACOs can lead the US towards maternal health equity

Article References: How Medicaid ACOs can lead the US towards maternal health equity. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: Medicaid ACOs, maternal health equity, MassHealth, postpartum care, prenatal care, postpartum depression screening, doula services, care coordination, social needs, The Milbank Quarterly, maternal mortality, health policy