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Accountable Health Communities (AHC) Model Evaluation First Evaluation Report

Leigh Evans, Abt Global; Janelle Armstrong Brown, Olivia Berzin, Megan Clayton, Laurie Cluff, Jim Derzon, Kathleen Farrell, Susan Haber, Caroline Husick, Echo Liu, Will Parish, Jules Payne, Jeanette Renaud, Lucia Rojas Smith, Holly Stockdale, and Adam Vincent, RTI International; Taressa Fraze and Danielle Hessler, Social Interventions Research Network (SIREN) at the University of California San Francisco


January 14, 2021

A person’s health is subject to a variety of social, economic, and environmental conditions. To address these issues holistically, Medicare and Medicaid clients sometimes need services beyond the purely medical. In 2017, the Center for Medicare & Medicaid Innovation launched the Accountable Health Communities (AHC) Model to test two interventions to help Medicare and Medicaid beneficiaries resolve health-related social needs (HRSNs) through navigation, meaning helping them make connections to community services that address needs for food, housing, utilities assistance, transportation, or domestic violence.

The initial report from Abt, RTI International, and the University of California San Francisco finds that the  AHC Model is effectively identifying higher cost and utilization beneficiaries, and these beneficiaries are accepting navigation at much higher rates than anticipated. Key findings include:

  • Early results show high acceptance of navigation and some utilization reductions among the high-need population targeted by the AHC Model.
  • Beneficiaries who qualified for the AHC Model intervention were disproportionately likely to be low income; racial and ethnic minorities; and, among Medicare beneficiaries, disabled.
  • Food insecurity was the most commonly reported HRSN.