The AHC Model is testing whether screening for social needs in clinical settings, referring high-risk Medicare and Medicaid beneficiaries to community services, and helping them navigate those services to address their needs decreases the utilization and cost of health care services.
Social and environmental factors make up 80 percent of the factors that determine a person’s health status, yet they are rarely assessed or addressed by the health care system. Bridging the gap between clinical care and community services may decrease health care costs and improve health.
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Health-related social needs such as stable housing, food security, protection from interpersonal violence, utility maintenance, and transportation availability are key drivers of health care utilization and cost. Yet it is often difficult for health care providers and systems to identify such needs and connect patients with appropriate services. To help bridge this gap between clinical care and community services, the Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) Model in 2017. The AHC Model initiative is an opportunity to apply a standard approach to identify and address health-related social needs among high-risk Medicare and Medicaid beneficiaries, with the goal of reducing health care utilization and cost. Mathematica supports CMS and AHC Model grantees by providing a peer-learning system, technical assistance, data management, and performance monitoring.
Evidence & Insights From This Project
Bridging the Gap: Identifying and Addressing Social Determinants of Health
The Accountable Health Communities Model initiative is an opportunity to apply a standard approach to identifying and addressing health-related social needs among Medicare and Medicaid beneficiaries to reduce health care utilization and cost.Learn More