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

Abstract

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 healthcare costs, the model aims to reduce avoidable healthcare utilization, impact the cost of healthcare, and improve health and quality of care for Medicare and Medicaid beneficiaries. He model will test whether systematically identifying and addressing beneficiaries’ health-related social needs impacts total healthcare 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: