Partnering for Impact: Early Insights from the Accountable Health Communities Model
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Associated Project
Accountable Health Communities: Identifying and Addressing Social Determinants of Health
Prepared for:
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
Key Findings
- Providing staff at clinical sites with data on social needs screening and navigation results helps them see the impact of screening for social needs and motivates them to do so.
- Integrating a standard health-related social needs screening tool in electronic health record systems and training staff to use the feature facilitates screening and can help with care coordination.
- Pre-visit phone screening for social needs increases efficiency in reaching rural patients.
From November 12-13, 2019, CMS held its second annual meeting for the AHC Model, which allowed bridge organizations to meet in person for networking and collaboration. Representatives from 29 bridge organizations, CMS staff, federal partners, and CMS contractors shared challenges and helpful strategies. Topics included: screening patients for health-related social needs, engaging patients in navigation to address social needs, and promising practices of cross-sector partnerships that build capacity of community services to address social needs.
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