What are Accountable Health Communities?

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced it would begin a five-year testing period of a new community-based health care program.  The Accountable Health Communities (AHC) model, will examine whether or not screening Medicare and Medicaid beneficiaries for health-related social needs will improve care and lower costs.  CMS hopes to study if the model can address “a critical gap between clinical care and community services in the current health care delivery system.”

AHC’s model will focus primarily on the health-related social needs of patients. The concept is based upon emerging evidence that addressing patient needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. CMS believes that ignoring health-related social needs may:

  • Increase the risk of developing chronic conditions
  • Reduce an individual’s ability to manage these conditions
  • Increase health care costs
  • Lead to avoidable heath care utilization.

This model will try to promote clinical community collaboration through:

  • Screening and referral of community-dwelling beneficiaries
  • Encouragement of alignment between clinical and community services.

Over this five-year period, CMS will implement and test three approaches or a ‘three-track model.’ Each track features interventions of varying intensity that link beneficiaries with community services such as community referral, service navigation and service alignment. Along with these tracks, CMS will award 44 cooperative agreements, ranging from $1 million to $4.5 million per awardee. Each of the tracks requires the award recipient to serve as a center that is responsible for coordinating efforts in testing in a specific track.

The ultimate goal for the model is to identify and address health-related social needs in housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs. CMS intends to test the impact on total cost of care through this evaluation using the model.

Advocacy Issue: 
Billing, Coding & Payments