The Centers for Medicare and Medicaid Services (CMS) announced a new, five-year Innovation Center initiative called the Accountable Health Communities (ACH) model. CMS said the ACH 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 beneficiaries’ impacts total health care costs, improves health, and quality of care.

“There is emerging evidence that addressing health-related socials needs through enhanced clinical-community partnerships can improve health outcomes and reduce costs,” CMS notes on the ACH website. “Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.”

ACH is a three track model for Medicare and Medicaid beneficiaries. Track 1 will increase beneficiary awareness of available community services; Track 2 will promote community service navigation to help high-risk beneficiaries access services; and Track 3 will encourage partner alignment to ensure that community services are available to beneficiaries.

CMS will award applicants 44 cooperative agreements from $1 million (Track 1) to $4.5 million (Track 3). The agency said CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by beneficiaries as a result of their participation in any of the three intervention tracks, but that award recipients will fund “interventions intended to connect beneficiaries with those offering such community services.”

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