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) was part of a team led by Mathematica that is serving as the AHC Model Implementation Technical Assistance contractor for CMCS. CHCS assisted 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: (1) led a series of focused Affinity Group activities; (2) organized and facilitated webinars and in-person learning sessions; and (3) participated in the Technical Assistance Advisory Board to design and deliver ongoing technical assistance to participating Bridge Organizations.

To learn about the experiences of bridge organizations that worked to connect patients, health systems, providers, and community organizations, read the CMS brief Partnering for Impact: Early Insights from the Accountable Health Communities Model.