The Accountable Health Communities 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 Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.
Select anywhere on the map below to view the interactive version
There are currently 28 organizations (list - XLS) participating in the Accountable Health Communities Model. To view an interactive map of this Model, visit the Where Innovation is Happening page, and select this model from the drop-down menu on the left side of the page.
To view an interactive map of this Model, visit the Where Innovation is Happening page.
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.
There are 28 organizations participating in the Accountable Health Communities Model.
A federal evaluation is underway and CMS will post results on this page when available.
Over a five year period, the model will provide 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 (i.e., housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs):
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 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 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 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).
Awareness Track Update
The Centers for Medicare & Medicaid Services (CMS) has withdrawn the Awareness Track Funding Opportunity for the Accountable Health Communities Model. The Funding Opportunity was withdrawn because CMS did not receive enough qualified applications to move forward with the Awareness Track. At this time, CMS does not intend to open a new funding opportunity for the model.
Questions about the model can be submitted to AccountableHealthCommunities@cms.hhs.gov.
Latest Evaluation Reports
- Two Pager: At-A-Glance Report (PDF)
AHC Screening Tool and Guides
- Accountable Health Communities Health-Related Social Needs Screening Tool (PDF)
- National Academy of Medicine article about the AHC Screening Tool (PDF)
- A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool (PDF)
Case Studies and Lessons Learned
- Planning for Sustainability and Advancing Health Equity during the Public Health Emergency (PDF)
- Preliminary Findings Fact Sheet (PDF) - October 2020
- Denver Regional Council of Governments: You’ve Got Mail! A Spotlight on Using Email to Screen for Health-Related Social Needs (PDF)
- Allina Health: Aligning Provider and Payer Activities to Address Social Determinants of Health (PDF)
- Building Strong Community Partnerships to Address Social Needs - Health Net of West Michigan Case Study (PDF)
- Health Quality Innovators Case Study (PDF)
- Using Data for Quality Improvement Case Study (PDF)
- Model Overview Fact Sheet - January 2016
- Press Release: CMS’ Accountable Health Communities Model
selects 32 participants to serve as local ‘hubs’ linking clinical and community services
- Funding Opportunity Announcement (FOA)
- Partnering for Impact: Early Insights from the Accountable Health Communities Model (PDF)
- New England Journal of Medicine article