Bridging the Gap: Identifying and Addressing Social Determinants of Health

Jun 27, 2017

Accountable Health Communities logoHealth-related social needs such as stable housing, food security, protection from interpersonal violence, and transportation are key drivers of health care utilization and cost, yet it is often difficult for health care providers and systems to identify such needs and connect patients with appropriate services. To help bridge this gap between clinical care and community services, the Center for Medicare & Medicaid Innovation (Innovation Center) in the Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) Model. The AHC Model initiative is an opportunity to apply a standard approach to identifying and addressing health-related social needs among Medicare and Medicaid beneficiaries in an effort to reduce health care utilization and cost. 

Map of Accountable Health Communities Model organizations
There are currently 32 organizations participating in the Accountable Health Communities Model.

Systematic implementation of the AHC Model as well as robust learning systems, technical assistance, and evaluation will help CMS determine the effect of identifying and addressing health-related social needs. Together with Ascend IST, the Center for Health Care Strategies, and HealthBegins, Mathematica Policy Research will provide community groups, known as “bridge organizations,” with educational content and technical assistance to help them effectively partner with clinical organizations and community service providers. Bridge organizations, selected by the CMS Innovation Center through a competitive grant process, will identify beneficiaries’ health-related social needs and help them access appropriate services. These bridge organizations serve rural and urban communities in 193 counties across 23 states. The organizations selected by CMS include provider organizations, academic institutions, and local governments. 

Mathematica and its partners will assist the CMS Innovation Center in testing and disseminating a screening tool and guide for assessing health-related social needs, implement a learning system, and provide technical assistance for the AHC bridge organizations. Mathematica and its team of experts will also monitor the bridge organizations’ progress and compliance with program rules, and they will collect and analyze program data to inform the learning system curriculum and program implementation. An independent evaluation will determine the impact of the model on quality of care and spending, including total health care costs and inpatient and outpatient health care utilization. 

“The AHC Model is a promising approach to integrating clinical care with social service supports,” according to Mathematica’s Craig Schneider, director of the AHC Model Implementation, Learning System, Technical Assistance, and Monitoring project. “By supporting the local bridge organizations in more effectively identifying and addressing health-related social needs, we look forward to helping the CMS Innovation Center reduce health care costs for Medicare and Medicaid and improve the health of their beneficiaries.”

Related Projects