Accountable Health Communities Model

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.

Select anywhere on the map below to view the interactive version

Accountable Health Communities Map

As of July, 2021, there were 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.


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 July, 2021, there were 28 organizations participating in the Accountable Health Communities Model.

A federal evaluation 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 (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 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).

Awareness Track Update

The Centers for Medicare & Medicaid Services (CMS) withdrew 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. 

Questions about the model can be submitted to


Latest Evaluation Reports

AHC Screening Tool and Guides

Case Studies and Lessons Learned

Additional Information

Last updated on: