Lessons Learned from Five Years of Identifying and Addressing Health-Related Social Needs

Lessons Learned from Five Years of Identifying and Addressing Health-Related Social Needs

Jan 11, 2024
Doctor with a clipboard talking to an older female patient

The Accountable Health Communities (AHC) Model, a Centers for Medicare & Medicaid Services (CMS) model supported by Mathematica, recently released lessons learned after five years of systematically identifying and addressing health-related social needs (HRSNs) for Medicare, Medicaid, and dually eligible individuals. These lessons learned can inform health care systems and community partners as they work to implement, sustain, or expand efforts to identify and address HRSNs, such as lack of housing, transportation, and food, for patients and communities.

“The AHC Model addressed a critical gap between clinical care and community services in the health care delivery system,” said Jennifer Dickey, project director and researcher at Mathematica. “Overall, this model yielded meaningful lessons for health organizations adopting screening, referral, and navigation practices to address the health-related social needs of their patients.”

The CMS Innovation Center created the AHC Model to support 28 awardees around the country to implement universal HRSN screening for eligible patients, refer patients to community-based organizations, and offer navigation services to help eligible patients access services. Notable lessons from the awardees’ work include:

  • Cultivate staff buy-in for effective HRSN screening. Clinical staff often have limited capacity and competing priorities. Awardees were more successful when they engaged staff in the development of screening workflows to foster a shared commitment to addressing HRSNs.
  • Center the patient experience in screening and navigation. Awardees found they were able to increase trust when they used patient-centered approaches to screening and navigation, such as motivational interviewing and trauma-informed care, and changed their approach based on patients’ feedback.
  • Build strong partnerships. Awardees invested time in building partnerships between health systems, community service providers, and the community members that HRSNs affect. They helped focus and motivate partners by developing common goals and sharing HRSN data at regular advisory board meetings.
  • Use data to identify disparities. Awardees used data from the AHC Model to identify populations with high rates of HRSNs—and where gaps in services were—and shared these data to drive decision making about allocating community resources.
  • Communicate the value of addressing HRSNs. Awardees customized communications about the AHC Model to different audiences. For example, they used different approaches to educate patients on the purpose of screening and to develop a business case for addressing HRSNs to prospective funders and payers.

Lessons from the AHC Model are also highlighted in an article in Health Affairs Forefront that discusses how the CMS Innovation Center can drive state investments in health-related social needs.

Mathematica supported the CMS Innovation Center with model implementation by providing a learning system and technical assistance for awardees, data management, and program monitoring. Check out the AHC Model webpage to read more insights, access screening resources, and learn how awardees are sustaining innovations from the model.