Accountable Health Communities Model

Multistate

CMS has selected 32 sites to participate in a 5-year program built around addressing patients' social needs. The program will conduct an inventory of local community services that are responsive to needs identified in community needs assessments, and partner with clinical delivery sites to conduct systematic health-related social needs screenings of all beneficiaries. Once social needs are identified, providers will refer patients to the appropriate community services. The goal of the program is to align stakeholders in order to optimize community capacity to address health-related social needs. Participating organizations are located in the following states: Arizona, Colorado, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maryland, Michigan, Minnesota, Mississippi, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia and West Virginia. 

Partner Organizations

• State Medicaid agencies

Target Population

Medicaid enrollees and Medicare beneficiaries with housing and/or complex needs

Care Team

Medical and behavioral health professionals

Timeframe

2017 - present

Results/ Studies

N/A

Funding

Federal grants

Resources

Program website