The Accountable Health Communities (AHC) care model launched in 2017 by the Center for Medicare & Medicaid Innovation has identified higher cost and utilization beneficiaries, who are accepting navigation at much higher rates than anticipated. According to the First Evaluation Report, the AHC model brought down emergency department (ED) visits by 9% for Medicare beneficiaries screened for health-related social needs.
- The AHC model has a 5-year period of performance beginning in May 2017 and ending in April 2022. Beneficiary screening began in summer 2018 following a pre implementation period. The Innovation Center funded entities known as bridge organizations to implement the model in communities in collaboration with clinical delivery sites, community service providers, state Medicaid agencies, and other community stakeholders.
- Many bridge organizations built on existing infrastructure for screening, referral, and navigation. Joining the AHC model allowed them to formalize and expand the scope of screening and referral and increase their capacity for navigation. They screened nearly 483,000 beneficiaries, out of which about 15% were eligible for navigation services.
- About one-third of screened beneficiaries had one or more core health-related social needs (HRSNs), but fewer than half of these reported having two or more ED visits in the 12 months before screening.
- Food insecurity was the most commonly reported HRSN among navigation-eligible beneficiaries in all bridge organizations except one, the report stated. The prevalence of food insecurity ranged from 53% to 82% at individual bridge organizations, and the median prevalence across bridge organizations was 69%.
- The report stated that although 40% of screenings occurred in hospital inpatient or ED settings, 61% of navigation-eligible beneficiaries were screened in these settings, indicating they were more likely to meet the navigation eligibility criteria than beneficiaries screened in other settings.
- Bridge organizations reported additional advantages of screening in EDs compared to primary care or clinic settings. EDs have a higher volume of non-repeat patients, ED wait times typically allow more time to complete the screening tool, and screeners have more time to connect with patients, which may increase acceptance of navigation.