Start: May 2018

Funder: Centers for Medicare & Medicare Services


Health-related social needs such as stable housing, food security, and transportation are primary drivers of health care utilization and cost, yet it is often difficult for health care providers and systems to identify social needs and connect patients with appropriate services. To help bridge this gap between health care providers and community services, the Center for Medicare & Medicaid Innovation (Innovation Center) in the Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) Model. The AHC Model initiative offers an opportunity to test whether a standardized approach to identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ will impact health care costs and reduce health care utilization.

The Center for Health Care Strategies (CHCS) is part of a team led by Mathematica Policy Research that is serving as the AHC Model Implementation Technical Assistance contractor for CMCS.  CHCS is assisting the 31 AHC awardees, (referred to as Bridge Organizations), in developing alliances with community resources to support population health with a focus on stakeholder engagement and peer-to-peer learning. In partnership with Mathematica, CHCS is: (1) leading a series of focused Affinity Group activities; (2) organizing and facilitating webinars and in-person learning sessions; and (3) participating in the Technical Assistance Advisory Board to design and deliver ongoing technical assistance to participating Bridge Organizations.