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:

• Screening of Medicare and Medicaid community-dwelling beneficiaries to identify certain unmet health-related social needs;
• Referral of Medicare and Medicaid community-dwelling beneficiaries to increase awareness of community services;
• Provision of navigation services to assist Medicare and Medicaid 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 Medicare and Medicaid community-dwelling beneficiaries.

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:

• 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 Medicare and Medicaid beneficiaries and make referrals to community services that may be able to address the identified health-related social needs;
• Coordinate and connect Medicare and Medicaid 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 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.

Accountable Health Communities (ACE) Presentation

For more information or information in other accessible formats, please contact:
Valerie Levy
Email: valerie.levy@tiftregional.com