In 2017, the Center for Medicare & Medicaid Innovation (Innovation Center) launched the Accountable Health Communities (AHC) Model to test whether connecting Medicare and Medicaid beneficiaries to community resources can improve health outcomes and reduce costs by addressing health-related social needs (HRSNs)—adverse social conditions that affect health and health care expenditures.
The AHC Model has a 5-year period of performance beginning in May 2017 and ending in April 2022. Beneficiary screening began in summer 2018 following a preimplementation period. The Innovation Center funded entities known as bridge organizations to implement the AHC Model in communities across the country in collaboration with clinical delivery sites (CDSs), community service providers (CSPs), state Medicaid agencies, and other community stakeholders. Bridge organizations are predominantly health systems and hospitals but also include nonprofits, health information technology providers, academic institutions, payers, and a public health agency. The model had 29 participating bridge organizations as of August 2019—11 in the Assistance Track and 18 in the Alignment Track.
Community-dwelling Medicare and Medicaid beneficiaries who live in a participating bridge organization’s Geographic Target Area are eligible for navigation if they have one or more of the five core HRSNs and selfreported having two or more emergency department (ED) visits in the 12 months before screening. These eligibility criteria are intended to identify high-need beneficiaries who can benefit from the AHC Model. Navigation Eligible beneficiaries in the Assistance Track are randomly assigned to an intervention group or a control group. Participants in the intervention group receive their usual clinical care and a community referral summary and are offered navigation; participants in the control group receive their usual care and the community referral summary. All navigation-eligible beneficiaries in the Alignment Track are in the intervention group and are offered navigation because the community-level continuous quality improvement component of the intervention is intended to affect all beneficiaries.
This report describes the Medicare and Medicaid beneficiaries who were eligible for the AHC Model in the Assistance Track and the Alignment Track through December 2019, including their sociodemographic characteristics, HRSNs, participation in navigation, and navigation outcomes. For both tracks, it also documents fee-for-service (FFS) Medicare beneficiaries’ health care expenditure and utilization patterns before they were screened. Model impacts for FFS Medicare beneficiaries eligible for navigation in the Assistance Track through September 2019 were assessed using Medicare claims through December 2019. In addition, the report describes bridge organizations and their CDS partners participating in the AHC Model and their experiences with screening, referral, and navigation.