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CSBG, Poverty

A New Opportunity to Connect Social and Physical Health

by Quinton Young, Program Assistant


The New Year can always be counted on for new beginnings! The Department of Health and Human Services (HHS) has announced a new funding opportunity of up to $157 million. This new program, the Accountable Health Communities (AHC) model, addresses the gap between clinical care and community services in the current health care system. This opportunity is designed to test whether screening beneficiaries for health-related social needs and providing referrals to needed services and programs will improve quality and affordability in Medicare and Medicaid. This funding opportunity emphasizes the need for both referrals to community-based services and support in navigating services and systems.

Community Action Agencies (CAAs) serve a substantial amount of seniors and individuals with disabilities, and many individuals served by CAAs are already enrolled in the Medicare and Medicaid programs. This opportunity is ideal for CAAs as many of these agencies have participants that are enrolled in the two key programs, they are an established and trusted service provider in communities around the nation, and are acutely aware that poverty and related social issues such as housing instability, hunger, and interpersonal violence effect the health of individuals over time.

The ties between social issues and health led to the creation of the five-year AHC model. This is the first program of the Centers for Medicare & Medicaid Services (CMS) Innovation Center that focuses on the health-related social needs of Medicare and Medicaid beneficiaries. The primary focus of the CMS for the purpose of testing “innovative payment and service delivery models to reduce program expenditures… while preserving or enhancing the quality of care”. This program attempts to save revenue for taxpayers by based on studies that analyze the amount of the money that the U.S government spends on healthcare issues that could be prevented. This model allows beneficiaries struggling with unmet health-related social needs to become aware of the community-based services available to them and to receive assistance accessing those services. The foundation of the Accountable Health Communities model is universal, comprehensive screening for health-related social needs of community-dwelling Medicare and Medicaid beneficiaries accessing health care at participating clinical delivery sites.

“We recognize that keeping people healthy is about more than what happens inside a doctor’s office, and that’s why, for the first time, we are testing whether screening patients for health-related social needs and connecting them to local community resources like housing and transportation to the doctor will ultimately improve their health and reduce the cost to taxpayers,”  — HHS Secretary Sylvia M. Burwell

The Department of Health and Human Services has taken a very proactive method to improving health care, particularly Medicare. This new program crosses lines upon multiple goals in the strategic plan of Secretary Sylvia M. Burwell, combining aspects of program efficiency, the strength of health care delivery, and advancing the health of the American people. Under this model, award recipients, referred to as “bridge organizations”, will oversee the screening of Medicare and Medicaid beneficiaries for social and behavioral issues, such as housing instability, food insecurity, utility needs, interpersonal violence, and transportation limitations, and help them connect with and/or navigate the appropriate community-based services.

With funding provided under the Affordable Care Act, the AHC will be able to support 44 bridge organizations. AHC will test three measurable approaches to health-related social needs and connecting clinical and community services. These three approaches are: community referral, community service navigation, and community service alignment. Bridge organizations will need to inventory local community agencies and provide referrals to those agencies as needed. They may also provide intensive community service navigation such as in-depth assessment, planning, and follow-up until needs are resolved or determined to be unresolvable for high-risk beneficiaries. We encourage the Community Action to be actively involved in this initiative. For more information, use the links below.

Letter of Intent           Grant Solutions           Frequently Asked Questions              Webinar


by Quinton Young, Program Assistant

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  1. Pingback: Reflections on the State of the Union 2016 | The State of Poverty - January 13, 2016

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