Screening, Referral, and Community Alignment to Address HRSNs: Early Lessons from the AHC Model
Evidence | Publications

Screening, Referral, and Community Alignment to Address HRSNs: Early Lessons from the AHC Model

Published: Oct 31, 2023
Publisher: Centers for Medicare & Medicaid Services
Health Delivery System Reforms Medicaid and CHIP Medicare Population Health Federal Advisory Services Technical Assistance Peer Learning
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Associated Project

Accountable Health Communities: Identifying and Addressing Social Determinants of Health

Time frame: 2017–2022

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

Authors

Laura Hanson

Mario Gruszczynski

Key Findings
  • This resource showcases strategies and lessons learned from awardees’ implementation of the AHC Model and findings from an early analysis of the model to provide insight and guidance to other organizations seeking to address HRSNs.
  • Awardees found strategies that helped them streamline screening, referral, and navigation workflows, cultivate staff buy-in, engage patients, and build relationships with community-based organizations to help address patients’ needs.
  • Awardees and CMS have leveraged lessons learned from the AHC model to inform work to address HRSNs beyond the AHC model’s end. Many awardees have expanded HRSN screening, referral, and navigation beyond the populations included in the AHC Model and CMS has incorporated lesson learned from AHC into other programs and models.

Drawing from AHC awardees implementation experiences, this resource captures some of the early lessons learned from the model that other organizations may consider as they address patients’ health-related social needs.

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