Fact sheet

Accountable Health Communities (AHC) Model
Assistance and Alignment Tracks Participant Selection

Accountable Health Communities (AHC) Model
Assistance and Alignment Tracks Participant Selection         

Many of the largest drivers of health and health care costs fall outside the clinical care environment. Health-related social needs are critical drivers of unnecessary health care utilization and costs, but are often difficult for providers to address without support. Many health systems lack the infrastructure and incentives to develop systematic screening and referral protocols and relationships to connect patients with community service providers to address their health-related social needs.

Last year, the Centers for Medicare & Medicaid Services (CMS) released a Funding Opportunity Announcement (FOA) for applications for the Center for Medicare and Medicaid Innovation’s (Innovation Center) Accountable Health Communities (AHC) Model. The model will support local communities to address the health-related social needs of Medicare and Medicaid beneficiaries by bridging the gap between clinical and community service providers. Organizations were encouraged to apply to become bridge organizations, and those that were selected to participate were funded to partner with clinical and community service providers that could identify and address beneficiaries’ health related social needs. By addressing critical drivers of poor health and high health care costs, the model aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries.

CMS received applications for the Assistance and Alignment Tracks from across the country in response to the FOA. After a review process, 12 Assistance Track and 20 Alignment Track bridge organizations were chosen to participate in the model. Bridge organizations were selected based on the following programmatic factors (as defined in the FOA): recommendations of the objective review panel, geographic diversity of applicants, applicants’ readiness to conduct the AHC intervention, scope of impact in the geographic target area, responsiveness to CMS’ inquiries and clarifications to their application, reviews for programmatic grants management, and reasonableness of the estimated cost to the government and anticipated costs.

The Accountable Health Communities Model includes a diverse range of organizations—varying in type (e.g., county governments, hospitals, universities, and health departments), size, location, and beneficiary demographics. The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, 2017 with a five-year performance period.

To view a list of the Assistance and Alignment Tracks bridge organizations in the Accountable Health Communities Model, please visit:

Model Background

The foundation of the Accountable Health Communities Model is universal, comprehensive screening for health-related social needs of community-dwelling Medicare and Medicaid beneficiaries accessing health care at participating clinical delivery sites. The model will test whether systematically identifying and addressing beneficiaries’ health-related social needs impacts total health care costs and reduces inpatient and outpatient utilization. In order to accomplish this, the Assistance and Alignment Tracks will implement and test separate service delivery approaches:

  • Assistance Track: Provide community service navigation services to assist high-risk beneficiaries with accessing services to address identified health-related social needs
  • Alignment Track: Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

To implement each approach, bridge organizations will serve 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 community-dwelling beneficiaries and make referrals to community services that may be able to address the identified health-related social needs;
  • Coordinate and connect high-risk community-dwelling 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).

The Awareness Track will test whether increased awareness of and referral to services addressing health-related social needs will impact total health care costs and utilization for Medicare and Medicaid beneficiaries in targeted communities.

There will be an independent evaluation of the Accountable Health Communities Model to determine the impact of the model on quality of care and spending, including total health care costs and inpatient and outpatient health care utilization. In order to accomplish this, the beneficiaries who receive services under Assistance Track will be randomized to different types of services, as well as receiving usual care. For the Alignment Track, CMS will use matched comparison groups.

The Accountable Health Communities Model is authorized under Section 1115A of the Social Security Act, which established the Innovation Center to test innovative payment and service delivery models to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or enhancing the quality of beneficiaries’ care.

For more information about the Accountable Health Communities Model, please visit: