Health Is A Web. Whole-Person Care Requires Whole-Community Systems

When people say “healthcare,” we tend to picture the exam room: a doctor, a prescription, a follow-up appointment.

But if you’ve spent any time listening to what families are actually dealing with, you know that’s only part of the story.

Health isn’t a single system. It’s a living web. Housing, food, transportation, childcare, utilities, safety, stress, behavioral health, and income stability all tug on the same thread. Pull one strand too tight—an eviction notice, a broken furnace, a missed ride to work—and the whole thing starts to unravel.

That’s exactly why concepts like Social Determinants of Health (SDOH) and Health-Related Social Needs (HRSN) became part of the conversation.

They name the reality that families are living through AND Community Action is already positioned inside that web—locally, statewide, and at scale.

Local Solutions Are a Health Strategy

Pennsylvania’s Community Action network includes 42 agencies serving all 67 counties. Each agency is built to respond to the needs of its community—based on regular Community Needs Assessments and a governance structure that includes public officials, community members, and stakeholders.

That local design matters in healthcare alignment because the “right” support in one county may be a completely different support in another. Rural access challenges, older housing stock, childcare deserts, workforce shortages, substance use patterns, transportation gaps—these don’t show up the same way everywhere.

Community Action is designed for that reality.

Whole-Person Care Needs a Whole-Community Ecosystem

If Pennsylvania is serious about “whole-person care,” then we need more than clinical capacity. We need a local, responsive ecosystem that can address socioeconomic needs alongside behavioral and physical health needs.

Community Action Agencies have been doing this work for decades. They’re trusted partners for families who make up to 200% of the Federal Poverty Level, and they understand that “stability” comes from layered support, long-term planning, and practical access to resources.

What Managed Care Is Being Asked to Do—and Why This Matters Now

Pennsylvania’s HealthChoices Physical Health Managed Care Organization (PH-MCO) contracts are increasingly explicit about partnering with community-based organizations and addressing HRSN barriers, reducing disparities, and improving maternal and child health.

One example is the Community-Based Care Management (CBCM) approach: it emphasizes a holistic model that includes assessing, referring, and helping mitigate health-related social needs, often with a strong preference for in-person, face-to-face engagement in homes and communities (not only screens and phone calls).

That requirement aligns naturally with how Community Action operates. Our agencies already work in the places people live, with the relationships and trust that make follow-through more likely.

This Isn’t Theoretical. It’s Already Happening.

Every year, Community Action Agencies report on services and outcomes tied to the Community Services Block Grant (CSBG). In 2024 alone, the network served 451,044 individuals across 224,789 households.

And when you look at services through SDOH domains, the scale becomes even clearer:

• Housing supports: 154,295

• Food and nutrition services: 271,608

• Maternal health supports: 38,681

• Behavioral health supports: 17,355

• Other health services (immunizations, screenings, vision/dental, etc.): 36,601

Community Action isn’t adjacent to healthcare priorities. We’re already executing them.

PA Navigate: Making the Web Easier to Use

One of the biggest practical challenges in “whole-person care” is referral follow-through. People are tired. Systems are fragmented. The handoff breaks down.

That’s why PA Navigate matters.

PA Navigate is built to connect Pennsylvanians to local health and social care resources—food, housing, utilities, transportation, childcare, employment support, and more—and it supports a closed-loop referral process, so referrals don’t vanish into the void.

CAAP’s role has been to help strengthen the network around it—engaging community organizations, supporting onboarding and training, and helping ensure the system becomes usable at the local level.

And the early operational signs are encouraging:

• All 42 CAAs are participating in PA Navigate

• Local CAAs have loaded 400+ programs

• 27 CAAs are part of the PA Navigate “Trusted Network,” with 212 programs actively accepting electronic referrals

• They’ve received 254 referrals, with 85% showing closed-loop status

Those numbers show the infrastructure of a healthier, more connected Pennsylvania.

Where This Is Going Next: Community Care Hubs

If we want this work to scale responsibly, we also need the operational backbone to support it—contracting, payments, data collection, referral coordination, security, shared infrastructure.

That’s where Community Care Hubs come in.

CAAs are well positioned for this model because they already have deep community roots, service-delivery experience, and partnerships across multiple SDOH domains.

CAAP has been working with local agencies through a development process to help launch Community Care Hubs across Pennsylvania, with multiple agencies preparing for that role.

This is how we build a “web” that holds without burning out local organizations or creating a patchwork of one-off pilots.

If You Want to Understand This Work, Start Local

Here’s a simple action step for anyone who wants to understand what “whole-person care” looks like in practice:

Find your local Community Action Agency.
Read their annual report.
Look at their Community Needs Assessment.
See what pressures families are naming in your county and what solutions are already in motion.

That’s where the real story is. Not in a slogan. Not in a statewide summary. In the local data, local priorities, and local partnerships that are already meeting needs every day.

And if you’re ready to explore partnership opportunities—through PA Navigate, Community Care Hub development, or aligned SDOH/HRSN initiatives—CAAP can help connect the dots.

Because health is a web.
Pennsylvania already has a network built for that reality.
Now we have to choose to use it.