Sustainable Strategies to Address Health-Related Social Needs through the Accountable Health Communities Model

Sustainable Strategies to Address Health-Related Social Needs through the Accountable Health Communities Model In the Accountable Health Communities (AHC) Model, participating organizations collaborate with clinical delivery sites and community service providers to address health-related social needs (HRSNs), including food insecurity, lack of transportation, and housing instability. These efforts aim to align clinical care and social services to reduce health care utilization and costs for Medicare and Medicaid beneficiaries. CMS recently released three new resources to share lessons learned from the AHC Model:  A Spotlight on Aligning Clinical Partners to a Collective Vision to Address Health-Related Social Needs highlights how model participant Rocky Mountain Health Plans used a multifaceted clinical engagement approach to ensure their clinical partners understood the urgency of addressing HRSNs. The spotlight includes successful strategies to build momentum for addressing HRSNs regionally, including opportunities to enhance buy-in from frontline staff. Leveraging Community Partnerships: How Advisory Boards Advance Screening, Referral, and Navigation Efforts highlights bridge organizations’ experiences working with advisory boards to address HSRNs, identify service gaps, and conduct quality improvement. The summary includes strategies and key takeaways for recruiting and engaging advisory board members to sustain screening, referral, and navigation activities beyond the AHC Model. November 2021 Virtual AHC Meeting Summary: Advancing Screening, Referral, and Navigation Beyond the AHC Model highlights key takeaways from the final AHC Meeting, which convened the 28 bridge organizations participating in the AHC Model and key partners, including community service providers, state Medicaid agency representatives, CMS leaders, and CMS contractors. The summary features insights on scaling and sustaining screening, referral, and navigation activities beyond the AHC Model. Best, The AHC Model Team

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