Leveraging community partnerships: How advisory board advance screening, referral, and navigation efforts

The Accountable Health Communities (AHC) Model addresses critical gaps in the current health care delivery system by examining whether systematically identifying and addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSNs) through screening, referral, and community navigation services impacts health care costs and reduces health care utilization. Since 2017, the AHC Model has supported its awardees, known as bridge organizations, to connect beneficiaries with HRSNs to community services to address those needs. Bridge organizations, which represent entities such as health systems, hospitals, and community-based organizations, participate in one of two tracks. This document focuses on the Alignment Track bridge organizations, which were required to establish multisector advisory boards to help ensure that community services are available and responsive to the needs of the beneficiaries. Advisory boards help with identifying community needs, use data to assist with planning for a gap analysis, and consider how to develop quality improvement processes.