The Area Agency on Aging is one of 20 organizations nationally selected by the Partnership to Align Social Care to join a Health Equity Learning Cooperative. During the 15-month initiative, the Area Agency on Aging will work to develop contract partnerships among DRCOG and the region's health care and health insurance providers. Through the program, Area Agency on Aging staff will convene a community-clinical team including its employees and staff from Denver Health, and a yet to-be-identified hospital, health system and health insurance provider. The team will design and implement a program to screen and navigate Medicare beneficiaries to community-based services. The program leverages three newly created Medicare reimbursable benefits which pay clinical providers to screen Medicare patients for social needs (such as housing and food) and reimburse DRCOG and clinical staff for labor costs to help patients find community services to meet their needs.