Insights from the Accountable Health Communities Model Final Evaluation Report

That webinar focused on the third evaluation report.

And again, you can find all of those on the website if you're interested in diving deeper.

So brief overview.

What was the AHC model? Model was launched actually in 2017 by the CMS Innovation Center.

At its core, CMS was asking a simple and important question.

Will systematically identifying Medicaid and Medicare patients with unmet social needs and connecting them to community resources reduce healthcare costs and utilization? So awards were originally made to 32 bridge organizations across the U.S.

that were committed to partnering across clinical and community organizations.

So together, the partnership screened more than 1.1 million beneficiaries for five specific drivers of health.

The model referred to these as core needs and could have added other needs to their list, but they included the ones that are on this list, housing instability, food insecurity, transportation problems, utility and security, and interpersonal violence.

Four sites ended up dropping out of the model.

The final report reflects findings from 28 organizations.

87% of the population served ultimately by the model were Medicaid only or dually eligible.

So the program really reached a high need, high cost population that was anticipated to benefit most from this kind of intervention.

The model came in two flavors, the assistance track and the alignment track.

Sites in the assistance track were part of an RCT.

In those sites, beneficiaries who screened positive for at least one core need and reported two or more ED visits and were community dwelling were randomly assigned to get a referral list about community resources and one-on-one navigation services whether on phone by phone or in person for up to 12 months the control group received the same referral list but no longitudinal navigation services so sites in the alignment track participated in a community quality improvement model so all of their eligible beneficiaries received navigation, but the award organizations and their partners were also asked to engage in system-level work to align community resource capacity and local needs.