Accountable Health Communities

Through the Accountable Health Communities,
proving that identifying and addressing a
patient’s health-related social needs through
cross-sector collaboration and patient
navigation DOES make a difference

In 2022, we concluded the CMS Accountable Health Communities (AHC) Model, a five-year initiative to test whether systematically identifying and addressing health related social needs (HRSNs) of Medicare and Medicaid beneficiaries (housing instability and quality, food insecurity, utility needs, interpersonal safety, and transportation) through screening, referral, and community navigation would reduce utilization and reduce inpatient and outpatient utilization.

Bridge organizations (such as PCCI) served as ‘hubs’ in their communities, forming partnerships with their state Medicaid Agencies, local clinical delivery sites (such as Parkland, our largest site), and community service providers to conduct HRSN screenings, navigate beneficiaries to community service providers in their communities, and align model partners to optimize community capacity to address the HRSNs. PCCI partnered with 17 clinical sites, representing the region’s top healthcare providers (e.g., Parkland) and more than 100 local community-based organizations (CBOs) to establish the Dallas Accountable Health Community (DAHC).