Case Study
Ruby Johnson, 72, lives with her husband in a remote farmhouse. She has diabetes, coronary artery disease and limited mobility due to arthritis. Both struggle with forgetfulness, finances and lack of transportation, which prevent Ruby from getting to regular medical appointments.
After a particularly bad fall, Ruby saw her doctor, who conducted a brief falls risk screening. Ruby was then connected with the Area Agency on Aging (AAA) located in her community for help.
Following the referral, a licensed AAA care manager conducted a comprehensive in-home needs assessment, which led to Ruby being enrolled in a no-cost, evidence-based program designed to help her better manage fall risks.
The AAA also worked with Ruby to create a person-centered care plan and to identify other services and supports she was eligible to receive. The care manager connected Ruby to services, including affordable transportation and installation of grab bars and handrails and arranged for caregiver support to help Ruby and her husband maintain their independence in their home.
Key Takeaways
- Community care, or care provided by trained community providers, is an array of home and community-based services (HCBS) provided to individuals and caregivers to promote overall wellness, including prevention, and assist with their functional and other support needs.
- Community care, often provided by licensed or professional social care workers, is its own specialty with training, knowledge and expertise on providing services and supports that improve a person’s health and enhance their quality of life.
- Community care is funded through many different sources in the United States, and so meeting a person’s needs often requires tapping a combination of programs and funding streams.
- Community care addresses upstream drivers of health, which encompass the social, environmental, behavioral and economic factors that affect a person’s ability to maintain their health and well-being. This is also known as whole person health.
According to a 2017 National Academy of Medicine report, only 10 to 20 percent of the contributors to health outcomes are attributable to medical or clinical care. Social or behavioral factors make up the other 80 to 90 percent. This tells us that health happens at home, and community care (often called social care) makes living at home possible for people with complex care needs and helps to improve health outcomes.
What Is Community Care?
Community care is an array of HCBS provided to individuals and caregivers to promote overall wellness and prevention and assist with their functional and other support needs. It includes services such as:
- Advance care planning
- Assessments
- Benefits outreach and enrollment assistance
- Care coordination
- Caregiver supports and training (including respite care)
- Employment-related supports
- Chronic disease management and falls prevention
- Help with daily activities (bathing, dressing, etc.)
- Home modifications
- Housing assistance
- Meals and other nutrition services
- Social connection programs
- Person-centered planning
- Physical activity programs
- Transitions from hospital to home and from nursing facility to home
- Transportation
Community Care as a Specialty: Who Provides This Care?
Like cardiology or geriatrics, community care is its own specialty with training, knowledge and expertise on providing services and supports that improve a person’s health and enhance their quality of life.
It is provided by trusted, local organizations with deep community roots and trust, including AAAs, aging services providers, community action agencies, senior centers, home care agencies and more.
These organizations provide services and supports utilizing a range of skilled professionals. Assessments, which start the care planning process, and case management/care coordination are usually led by a case manager, who is a licensed or professional social care worker.
Other professionals who are part of the Aging Network include nurses, social workers, dieticians and nutritionists, public benefits specialists, information and assistance specialists, community health workers, transportation providers and home care aides.
These licensed or professional social care workers are specially trained to serve a variety of populations, conduct comprehensive needs assessments, determine financial and functional eligibility, understand the various funding sources and related systems requirements to provide the appropriate care, and how community care services should be provided.
Funding for Community Care
Community care in the United States is funded through many different sources, including federal programs such as Medicaid and, increasingly, Medicare; the Older Americans Act (OAA); human services block grants; and private philanthropy.
However, the United States spends significantly less on social services than many other developed countries. Since their inception in 1965, spending on Medicare, Medicaid and CHIP has far outpaced spending on community care programs such as the OAA.
A majority of a person’s health and well-being happens at home, making community care essential for supporting healthy, independent living. Trusted community-based providers bring deep local knowledge and specialized expertise to deliver personalized, coordinated services that improve health outcomes and advance whole person care.
About USAging
USAging is the national association representing and supporting the network of Area Agencies on Aging and advocating for the Title VI Native American Aging Programs. Our members help older adults and people with disabilities throughout the United States live with optimal health, well-being, independence and dignity in their homes and communities.
Sources
- Magnan, S. (2017). Social Determinants of Health 101 for health care. National Academy of Medicine.
- Organisation for Economic Co-operation and Development. (2022). Social Expenditure Dashboard.
- Cubanski, J., Burns, A., & Cox, C. (2025). What Does the Federal Government Spend on Health Care?. KFF.
This briefing series was made possible with generous support from CCS Health®.