Accountable Health Communities (AHC) Model evaluation: Second evaluation report

In 2017, the Center for Medicare & Medicaid Innovation (Innovation Center) launched the Accountable Health Communities (AHC) Model to test whether connecting Medicare and Medicaid beneficiaries to community resources and addressing health-related social needs (HRSNs)—adverse social conditions that affect health and health care expenditures—can improve health outcomes and reduce costs. The Innovation Center funded entities known as bridge organizations to implement the AHC Model in communities across the country in collaboration with clinical delivery sites (CDSs), community service providers (CSPs), state Medicaid agencies, and other community stakeholders. The Innovation Center originally funded 32 bridge organizations, but four voluntarily terminated their participation early on. The AHC Model’s initial 5-year period of performance concluded in April 2022, but 18 bridge organizations received no-cost extensions to continue model activities for an additional 3 to 12 months.

Under the model, community-dwelling Medicare and Medicaid beneficiaries who live in a participating bridge organization’s Geographic Target Area (GTA) were screened for five core needs: housing instability, food insecurity, problems with transportation, difficulties with utilities, and interpersonal violence. Beneficiaries were eligible for community service navigation if they had one or more of the five core HRSNs and self-reported having two or more emergency department (ED) visits in the 12 months before screening. These eligibility criteria were intended to identify high-risk beneficiaries who could benefit from the AHC Model. Medicare and Medicaid beneficiaries in both fee-for-service (FFS) and managed care were eligible for the model.

The model tested whether two separate interventions (Assistance versus Alignment) could impact health care utilization and costs by helping Medicare and Medicaid beneficiaries with HRSNs resolve those needs