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Arizona Strategies
Social Determinants of Health Screening and Referral: Arizona CommunityCares    

In 2019, Arizona’s Medicaid agency established a Whole Person Care Initiative (WPCI) to address social determinants of health and well-being. As part of this initiative, the state developed a statewide closed-loop referral system called CommunityCares, powered by Unite Us. CommunityCares allows health and mental health care and community service providers to track screening, referrals, and service delivery for SDOH-related social services, such as housing, food, transportation, and employment. It integrates with existing health IT systems (e.g., electronic health records) and is able to deliver personalized referrals in response to patient needs based on location, language, and eligibility requirements. It was developed for the state Medicaid program by Contexture, a health information exchange that operates in Arizona and Colorado, and Unite Us, which provides the technology platform.

CommunityCares can be joined for free by healthcare providers and community-based organizations (CBOs) that offer healthcare, mental health services, and social care services such as parenting classes, early care and education programs, home visiting, and domestic violence shelters. Participating organizations agree to meet network standards (e.g., will respond to referrals within specified time periods) and undergo onboarding and training. As participating members, these organizations can send and receive referrals through CommunityCares. The system does not require healthcare providers to use a formal SDOH screening tool, though some are available through CommunityCares. Examples include the Income, Housing, Education/Employment, Legal Status, and Personal and Family Stability and Safety (I-HELP) Social History Tool, the Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE), and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). While CommunityCares does not provide active management of referrals and cases, it does send automated reminders if an organization does not respond to a referral.

Arizona has developed incentives to encourage use of CommunityCares by enrolled healthcare providers and CBOs. There are two mechanisms for incentivizing healthcare providers to conduct SDOH screening and refer families to CommunityCares. As part of its Section 1115 Waiver, Arizona Medicaid has a program called Targeted Investments 2.0, which offers payments to providers who achieve milestones that support behavioral health and physical health integration and coordination. Targeted Investments 2.0 offers incentive payments for meeting targets to participating CommunityCares healthcare providers, including pediatric primary care. These targets include annual SDOH screenings with a tool covering at least food insecurity and homelessness/housing instability and, in the case of positive screens, making referrals through CommunityCares.

The second mechanism, for providers is called a Differential Adjusted Payment (DAP). The DAP is an incentive payment to providers for meeting certain targets. To receive the 1 percent incentive payment for contract year 2024, providers must be enrolled with CommunityCares and facilitate at least 10 referrals per month resulting from use of a SDOH screening tool.

Contexture also offers programs to encourage CBO engagement and adoption of CommunityCares. These programs offer financial incentives for CBOs to use CommunityCares and support successful adoption to offset costs of technology and training. Payments for the CBO programs are pending funding availability at the time of onboarding and completion of activities. Incentive payments have been offered for meeting milestones such as going live on CommunityCares as an organization that receives referrals and responding to referrals within a specified amount of time. Additionally, Contexture offers the Assistance Reimbursement program to fund necessary technology solutions, equipment, and support staff training for CBOs. Neither healthcare providers nor CBOs are required to participate in these incentive programs to use CommunityCares.

During this early period, CommunityCares has focused its efforts on recruiting healthcare providers and CBOs to join the network. Many healthcare providers, particularly hospitals, had preexisting interest in SDOH. The backing of Medicaid and its incentive payment program offered additional encouragement, as did the promise of a system that integrates seamlessly with healthcare IT systems they already use.

To recruit CBOs, CommunityCares worked with healthcare providers to identify their existing referral pathways and encourage them to join. It also incorporates the resources of the Arizona 2-1-1, the state’s existing 24-hour live-operator health and human services hotline. To ensure the referral network is diverse in terms of geography, populations served, and services provided, CommunityCares has teams that meet with local coalitions of CBOs and attend conferences to connect with providers and invite their participation in CommunityCares. Stakeholder engagement groups, including one specific to CBOs, helped CommunityCares refine its recruitment strategy. For example, these groups advised that there are certain regions of the state where in-person rather than virtual recruitment is critical. As with healthcare providers, incentive payments offer additional motivation for CBOs to join. CBOs can earn $2,000 for completing enrollment in the system and opting in to receive referrals. For responding to 75 percent of referrals within two business days for six months CBOs can earn $3,000 and for 12 months they can earn an additional $5,000.

For healthcare providers and CBOs that join the network, CommunityCares offers live training      and self-paced training modules, as well as check-ins at 30, 60, and 90 days once they have gone joined the platform. live. As a part of the onboarding, CommunityCares works with healthcare providers to consider how SDOH screening will change their workflow and procedures, either because SDOH screening is new to them or they will have a new system for SDOH screening and referrals. CommunityCares not only explains the importance of SDOH screening, but also asks providers to consider the SDOH needs they are hoping to address and the purpose of the screening for their organization. In each of the healthcare providers and CBOs that have successfully implemented SDOH screening and referrals with CommunityCares a champion within the organization has led use of the system.  


Funding for the development and operation of CommunityCares comes from the state Medicaid program’s Whole Person Care Initiative. Medicaid is also the source of funding for incentive payments to healthcare providers and, in combination with foundations, to CBOs.

Evaluation and Monitoring

While CommunityCares does not look at the referrals and outcomes for individual patients, it can analyze aggregate data to identify needs for particular populations or geographic areas (e.g., high need for transportation found in screening but no places to refer) and to drive efforts to improve referral sources. CommunityCares is developing metrics but this work is in an early phase.

 As of October 2023, 703 organizations are enrolled, offering 1,569 programs, and 2,514 people have been referred, with an average of 1.9 referrals per person.

Special thanks to the following individuals for providing information for this profile: Sebastian Blackwell and Brandon White, Unite Us; Kelly McGann, Contexture; and Melissa Del-Colle, Megan Woods, Cameron Adams, Mary Beardsley, and Chy Porter, Arizona Health Care Cost Containment System.

Last updated October 2023. We are planning to update this profile soon to include examples of healthcare providers’ experiences using CommunityCares to support families with young children.

IECMH in ECE and Home Visiting: Smart Support

Smart Support early childhood mental health (ECMH) consultation services are offered to licensed child care centers, regulated family child care providers, and home visiting teams in regions throughout Arizona that have elected to use state-allocated tobacco tax revenue for such services. This revenue is administered by First Things First, an initiative created through a voter proposition that provides funding for locally-selected early childhood programs and services. In some areas of the state, Smart Support consultation is also provided to unregulated family, friend, and neighbor (FFN) child care providers served by three FFN networks. A recent expansion of Smart Support services now includes consultation to 50 home visiting teams, which use the following evidence-based models: Nurse-Family Partnership, Healthy Families America, Parents as Teachers, and Family Spirit.

Southwest Human Development (SWHD), a nonprofit agency focused on birth-to-five services, is the administrative home and largest provider of consultants for Smart Support. SWHD subcontracts with two other agencies to provide Smart Support services in locations outside its service area. There are currently 42 consultants providing Smart Support services to early care and education providers and home visiting teams across the state, with typical caseloads per consultant of 8-9 early care and education providers and one home visiting team.

IECMH Consultation in Early Care and Education Settings

In early care and education (ECE) settings, consultants work with teachers, other staff, and families to increase their capacity to support early childhood mental health and reduce challenging behavior. They focus on an identified child, the classroom, the program, or a combination of these. Consultants receive training and employ strategies based on two models: the Pyramid Model, which helps consultants understand and address children’s mental health needs within the context of ECE settings, and FAN (Facilitating Attuned INteractions), which provides guidance on effective methods for consultants to use in working with ECE staff and parents. They further participate in ongoing professional development on topics related to adult mental health; infant-early childhood mental health; child development; equity, diversity and inclusion; and professional consultation.

A consultant typically provides assistance in an ECE setting for 2-3 hours a week. Consultation is open-ended, continuing until agreed-upon goals are met, although it typically lasts for a year with a given provider. Consultants work with teachers and parents to develop strategies that address the needs of an individual child, and also help teachers use practices that support the social-emotional growth of all children in an ECE setting. Consultants also help families connect with community resources related to parent, child, and family needs. When a consultant is not immediately available, “waitlist consultation” is provided by telephone to a center director or occasionally to an ECE teacher. This consultation helps the program address a particular problem in the short-term and prepares the staff for consultation when it becomes available. In most areas of the state, only a few providers are on the waitlist at any time and they typically receive on-site consultation within a few weeks. However, in some rural regions providers may remain on the list for several months.

Smart Support has a contract to work with an agency that serves family, friend, and neighbor (FFN) providers. The FFN Specialists from this agency offer a 10-week training curriculum to FFN providers at a central location. Smart Support consultants attend each of these sessions in-person and also co-lead a session that is devoted to social-emotional development. They consult with the FFN Specialists for an hour prior to each training session with the overall goal of building their capacity to support FFN providers’ ability to address behavioral, social-emotional, and family challenges. The consultants are available at each session to answer providers’ questions and then meet again with the FFN Specialists at the conclusion of each training session to discuss how the training went and respond to any questions or observations the specialists have. Mental health consultation to FFN Specialists was a response to the specialists’ reports about feeling unprepared to address the behavioral and social-emotional concerns of children and families that FFN providers discuss with them. In addition to their weekly in-person consultations, Smart Support consultants are also available for phone consultations with the FFN Specialists as needed. These consultations can address FFN Specialists’ concerns related to a particular FFN provider or more general IECMH strategies. Smart Support consultants can also guide FFN Specialists in making referrals for the children and families in the FFN providers’ care (e.g., for a child developmental evaluation or parent-child therapy), or for the FFN providers’ own mental health needs.

Because the Smart Support consultants are bilingual, they have worked well with the predominantly Spanish-speaking FFN provider population. FFN network administrators and Specialists have provided very positive informal feedback on Smart Support consultation services.

IECMH Consultation in Home Visiting

IECMH consultation to home visiting teams is a robust part of Smart Support. Home visiting teams are comprised of the home visitors (approximately 5-8) and their supervisor. The consultant offers guidance on understanding and addressing the mental health issues of parents and children, including difficulties in parent-child relationships. If indicated, the consultant supports referrals to additional mental health services. In some cases, the consultant will accompany the home visitor on a visit, serving as an “ambassador” of mental health in order to facilitate a referral. The consultant also helps home visitors develop their reflective practice skills so they are better able to consider their experience and reactions and those of families. Consultants integrate information about ways to address various mental health and relational challenges that parents and children face into discussions with home visitors about individual families, but this information is sometimes also taught in more formal trainings.

Smart Support consultants spend two hours a month in-person with each home visiting team discussing cases and conducting pre- and post-meeting phone calls, which are used to plan home visits. In addition, the consultants are available on an “as-needed” basis for phone consultations with the home visiting teams, often related to urgent need. Consultants help the supervisor and home visitor think through referrals for families in need of substance abuse treatment, domestic violence resources, and supports for other serious needs.

Recruitment of home visiting teams involved outreach through agencies that provide home visiting, as well as presentations at home visiting team meetings. The state agencies in Arizona that fund home visiting programs sent an introduction letter out to all home visiting managers to inform them of opportunity to add mental health consultation to their team meetings. There was great interest and all slots were quickly filled.

Workforce Development

Smart Support consultants serve a mix of ECE programs and home visiting teams. All consultants are required to have a master’s degree in a license-eligible mental health discipline such as social work, counseling, or marriage and family therapy. They are also required to have at least one year of postgraduate professional experience. Supervisors must be licensed and have a minimum of five years of relevant postgraduate experience.

Smart Support provides extensive pre- and in-service training and ongoing supports. New consultants participate in a two-week orientation, followed by a year-long training period that covers the Smart Support consultation model, service delivery, reflective supervision, evaluation and database training, the Pyramid Model, and the FAN approach. Consultants also participate with their peers in a monthly book club discussion about a book related to early childhood mental health or consultation.

In-person statewide trainings for all consultants are held twice a year. Consultants may also apply to the Harris Infant and Early Childhood Mental Health Training Institute at Southwest Human Development, with tuition covered by Smart Support. The two-year training consists of monthly daylong sessions that cover the principles and practices of infant mental health.

Consultants participate in weekly hour-long supervision and monthly group supervision meetings, which blend discussion of administrative issues with reflection on consultation work. In turn, supervisors and Smart Support program managers also receive weekly hour-long supervision. Supervisors and program managers have weekly leadership meetings, and program managers meet weekly with the program’s director so that there is ample opportunity throughout the Smart Support program structure for reflection, problem-solving, and creativity.


Smart Support is offered free to eligible early care and education providers and home visiting teams through funding from First Things First, an initiative that directs dedicated revenues from a state tobacco tax to quality birth to five early education and health programs. The state is divided into 33 First Things First regions, each with a local regional council that develops a plan of services to be delivered. Smart Support will serve any region that chooses to opt in to ECMH consultation services. Smart Support services are offered to licensed child care centers and regulated family child care providers in 14 First Things First regions. Half of those 14 regions represent the most populated areas of Arizona. Home visiting consultation is offered in 20 regions, and FFN consultation is offered in three.

Smart Support has contracts with three tribal Head Start programs outside of First Things First funding: Colorado River Indian Tribe, Hualapai Tribe, and Salt River Pima Maricopa Indian Community.

Funding for consultation to 40 of the 50 home visiting teams comes through a grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) that will end in September 2020. Program leaders are meeting with state stakeholders to try to sustain the current volume of home visiting consultation.

Evaluation and Monitoring

An external evaluation of Smart Support was conducted from April 2010 through May 2014, a period in which Smart Support services were delivered to 521 child care centers, 48 licensed family child care providers, and 1,569 teachers. Data were collected at baseline, six months, and 12 months through questionnaires, observations, and surveys.

The evaluation found significant improvements, which were especially pronounced during the first six months, across a wide range of outcomes: classroom mental health climate, teacher self-efficacy, teacher-child relationships, children’s self-regulation, children’s attachment, children’s initiative, children’s risk of expulsion, and teachers’ negative attributions of individual children. Directors and teachers reported strong satisfaction with the program. Consultants’ positive ratings of their relationships with teachers were related to greater growth in key teacher and classroom outcomes.

Currently Smart Support collects data on ECE providers served, including provider characteristics (e.g., years of experience, education level), characteristics of the child care settings, type of consultation (e.g., child, classroom, or programmatic consultation), dosage, and duration, as well as fielding satisfaction surveys for providers. For home visitors, Smart Support tracks the number of home visitors who attend case consultations and professional development provided by consultants. For FFN, Smart Support tracks the number of participants and characteristics of referrals provided to families and FFN caregivers.

Smart Support consultants continue to use some of the 20 measures from the evaluation to guide quality improvement and clinical work. These measures help the consultants develop plans and goals for their work, as well as track progress. For example, consultants providing classroom- and child-centered consultation use the observational Preschool Mental Health Climate Scale, which assesses transitions, staff affect, teaching feelings and problem-solving, and staff-child interactions, to guide their work and to provide feedback to center directors. When engaging in child-centered consultation, ECMH consultants use the teacher-completed Student-Teacher Relationship Scale to inform their work.

Last updated May 2020

Special thanks to the following individuals at Southwest Human Development for providing information for and reviewing this profile: Alison Steier, Vice President, Mental Health Services, and Leah Eckley, Assistant Director, Mental Health Services.