Promising strategies for community service navigation: Lessons from health quality innovators

The Accountable Health Communities (AHC) Model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries
through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.

The model provides support to community bridge organizations to test promising service delivery approaches aimed at linking beneficiaries with community services that may address their health related social needs (i.e., housing instability, food insecurity, utility needs, interpersonal violence,
and transportation needs).