Accountable Health Communities Model

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The Accountable Health Communities (AHC) model addresses 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 beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery.

Background

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 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.

Initiative Details

Over a five-year period, CMS will implement and test a three-track model based on promising service delivery approaches. Each track features interventions of varying intensity that link beneficiaries with community services:

Track 1 Awareness – Increase beneficiary awareness of available community services through information dissemination and referral

Track 2 Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services

Track 3 Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries

Each of the tracks requires the award recipient to serve as a hub responsible for coordinating efforts to:

Identify and partner with clinical delivery sites (CDS) (e.g., clinics, hospitals);
Conduct systematic health-related social needs screenings and make referrals for all eligible Medicare and Medicaid beneficiaries;
Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs and who are randomized to the intervention group to community service providers that might be able to address those needs; and
Align model partners to optimize community capacity to address health-related social needs (Track 3 only).

CMS will award up to 44 cooperative agreements ranging from $1.17 million (per Track 1 site) to $4.5 million (per Track 3 site) to successful applicants to implement the Accountable Health Communities model. Applicants will partner with state Medicaid agencies, clinical delivery sites, and community service providers and are responsible for coordinating community efforts to improve linkage between clinical care and community services.

CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by community-dwelling beneficiaries as a result of their participation in any of the three intervention tracks. Award recipients, however, must use their award monies to fund interventions intended to connect community-dwelling beneficiaries with those offering such community services.

Initiative Goals

The Model aims to identify and address beneficiaries’ health-related social needs in at least the following core areas:

Housing instability and quality;
Food insecurity;
Utility needs;
Interpersonal violence; and
Transportation needs.

The evaluation will test the impact of the Accountable Health Communities interventions on total health care costs and inpatient and outpatient health care utilization, as well as health and quality of care for Medicare and Medicaid beneficiaries. CMS will test whether community referral, community service navigation, or community service alignment impacts total cost of care, emergency department visits, inpatient hospital admissions, and quality of care for high-risk Medicare and Medicaid beneficiaries.

Eligibility

The application period is now closed and applications are currently under review.

Eligible applicants included community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations and for-profit and not-for-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers.

Questions about the model and applications can be submitted to AccountableHealthCommunities@cms.hhs.gov.

To sign up for updates about this model, please subscribe to the Accountable Health Communities Model listserv.