The Accountable Health Communities Model addressed a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.
As of April, 2022, there were 28 organizations (list - XLS (XLS)) participating in the Accountable Health Communities Model.
Background
The Accountable Health Communities Model was based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.
This model promoted clinical-community collaboration through:
- Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
- Referral of community-dwelling beneficiaries to increase awareness of community services;
- Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
- Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.
As of April 2022, there were 28 organizations participating in the Accountable Health Communities Model.
A federal evaluation of the model is underway, and CMS will post results on this page when available.
Initiative Details
Over a five-year period, the model provided support to community bridge organizations to test promising service delivery approaches aimed at linking beneficiaries with community services that may address their health-related social needs (HRSNs):
Assistance Track – Provide community service navigation services to assist high-risk beneficiaries with accessing services to address health-related social needs
Alignment Track – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries
To implement each approach, bridge organizations served as ‘hubs’ in their communities, forming and coordinating consortia that will:
- Identify and partner with clinical delivery sites (e.g., physician practices, behavioral health providers, clinics, hospitals) to conduct systematic health-related social needs screenings of all beneficiaries and make referrals to community services that may be able to address the identified health-related social needs;
- Coordinate and connect beneficiaries to community service providers through community service navigation; and
- Align model partners to optimize community capacity to address health-related social needs (Alignment Track only).
Funds for this model supported the infrastructure and staffing needs of bridge organizations and did not pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, utilities, or transportation).
Evaluations
Latest Evaluation Reports
- Two-Pager: At-a-Glance Report (PDF)
Prior Evaluation Reports
- Two Pager: At-A-Glance Report (PDF) - 05/2023
- Two Pager: At-A-Glance Report (PDF) - 12/2020
AHC Screening Tools and Protocols
- A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool (PDF) - updated 12/2023
- Accountable Health Communities Health-Related Social Needs Screening Tool Citation and Notification Information (PDF) - 9/2021
- Accountable Health Communities Health-Related Social Needs Screening Tool - English (PDF)
- Translations of the Accountable Health Communities Health-Related Social Needs Screening Tool:
- National Academy of Medicine article about the AHC Screening Tool (PDF) - 5/2017
Emerging Best Practices and Lessons Learned
Lessons Learned
- Scaling and Spreading Innovations from the Accountable Health Communities Model (PDF)
- Screening, Referral, and Community Alignment to Address HRSNs: Early Lessons from the Accountable Health Communities Model (PDF)
- Almost Two Million Completed Social Needs Screenings: Addressing a Critical Gap (PDF)
- Accountable Health Communities (AHC) Model Awardees Communicate the Value of Addressing Health-Related Social Needs (PDF)
- Building Strong Community Partnerships to Address Social Needs (PDF)
- Health Affairs Forefront article: Lessons from Five Years Of The CMS Accountable Health Communities Model - 8/2022
Sustainability
- Expanding and Scaling Efforts to Identify and Address Health-Related Social Needs - Ballad Health (PDF) - 1/2023
- Making the Business Case for Addressing Health-Related Social Needs - Reading Hospital Spotlight (PDF) - 6/2022
- Aligning Provider and Payer Activities to Address Social Determinants of Health - Allina Health Spotlight (PDF) (PDF) - 7/2021
Implementation
- Leveraging Community Partnerships: How Advisory Boards Advance Screening, Referral, and Navigation Efforts (PDF) - 2/2022
- Aligning Clinical Partners to a Collective Vision to Address Health-Related Social Needs – Rocky Mountain Health Plans Spotlight (PDF) - 2/2022
- You’ve Got Mail! Using Email to Screen for Health-Related Social Needs - Denver Regional Council of Governments Spotlight (PDF) - 6/2021
- Promising Strategies for Community Service Navigation - Health Quality Innovators Case Study (PDF) - 7/2019
- Building Strong Community Partnerships to Address Social Needs - Health Net of West Michigan Case Study (PDF) - 4/2021
Data
- Engaging Clinical and Community Partners to Select and Implement a Common Referral Platform – United Way of Greater Cleveland Case Study (PDF) - 10/2022
- Cross-Sector Data Sharing to Address Health-Related Social Needs: Qualitative Data Collection Summary (PDF) - 10/2022
- Using Data for Quality Improvement - St. Joseph's Hospital Case Study (PDF) - 10/2019
Model Information and Specifications
- AHC Fact Sheet and Preliminary Findings (PDF) (PDF)- 10/2020
- Model Overview Fact Sheet - 1/2016
- Press Release: CMS’ Accountable Health Communities Model selects 32 participants to serve as local ‘hubs’ linking clinical and community services - 4/2017
- Funding Opportunity Announcement (FOA) - 1/2016
Summaries of Annual Meetings
- Advancing Screening, Referral, and Navigation Beyond the AHC Model: November 2021 Virtual Meeting Summary (PDF)
- Planning for Sustainability and Advancing Health Equity during the Public Health Emergency: February 2021 Virtual Meeting Summary (PDF) - 2/2021
- Partnering for Impact: Early Insights from the Accountable Health Communities Model: November 2019 Annual Meeting Summary (PDF)
Additional Information