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
A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool
Health-related social needs (HRSNs) refer to social conditions that negatively impact one’s health. As more providers screen for HRSNs, we developed this guide to describe the HRSN Screening Tool from the Accountable Health Communities Model and to share promising practices with a broader audience.Learn More
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