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Evaluating the Accountable Health Communities (AHC) Model


  • Can identifying—and treating—health-related social needs reduce health care costs and utilization?
  • Abt is using a mixed methods approach to evaluate AHC implementation and outcomes.
  • Future results are expected in 2024.
The Challenge

CMS launched the Accountable Health Communities (AHC) Model to address the gap between clinical care and community services in the health care system. The AHC Model is based on emerging evidence that addressing health-related social needs can improve health outcomes. Abt, as a sub-contractor to RTI, is 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 Approach

The AHC evaluation is using a mixed methods approach to describe AHC communities and to gather data from model implementers and the Medicare and Medicaid beneficiaries they serve. Abt’s main responsibilities within the evaluation include delivering community profiles, a beneficiary survey and beneficiary interviews, and a survey of and interviews with community service providers. Other parts of the evaluation include claims analyses, interviews with other stakeholders and a qualitative comparative analysis (QCA) of factors related to success. 

The Results

Through December 2021, more than 1 million Medicare and Medicaid beneficiaries were screened by AHC bridge organizations, and more than three-fourths of eligible beneficiaries agreed to participate in health-related social needs (HRSN) navigation.  Early data show that almost two-thirds of beneficiaries did not have any resolved HRSNs after completing navigation and navigation did not increase their connection to community services or HRSN resolution. Gaps between community resources and beneficiary needs may have reduced navigation impacts. Other findings show that the model reduced Emergency Department (ED) visits for both Medicaid and fee-for-service Medicare beneficiaries in the Assistance Track. Qualitative interview data suggest that navigators may be helping beneficiaries access appropriate, non-ED care. Future results are expected in 2024.