The Accountable Health Communities Model is 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 will promote clinical-community collaboration through:
There are 32 organizations participating in the Assistance and Alignment Tracks of the CMS Accountable Health Communities Model.
Over a five year period, the model will provide support to community bridge organizations to test promising service delivery approaches aimed at linking Medicare and Medicaid beneficiaries with community services that may address their health-related social needs (i.e., housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs):
Awareness Track – Increase Medicare and Medicaid beneficiary awareness of available community services through information dissemination and referral
Assistance Track – Provide community service navigation services to assist Medicare and Medicaid 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 Medicare and Medicaid beneficiaries
To implement each approach, bridge organizations will serve as ‘hubs’ in their communities, forming and coordinating consortia that will:
Funds for this model support the infrastructure and staffing needs of bridge organizations, and do not pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, utilities, or transportation.
For more information or information in other accessible formats, please contact: