CMS Model Helps Address the Health-Related Social Needs for over 750,000 Medicare and Medicaid Beneficiaries

October 2, 2020

In June, CMS Administrator Seema Verma issued a call to action, noting that “the transition to a value-based system has never been so urgent. When implemented effectively, it encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life.”

As part of CMS’s focus on delivering better health care value, for the first time, CMS is sharing a fact sheet with a snapshot of the data from the Accountable Health Communities (AHC) Model, reflecting the agency’s most comprehensive collection of social needs data to date. One in three beneficiaries (33 percent) reported at least one core health-related social need. Food needs were the most commonly reported (67 percent of those reporting at least one need), followed by housing (47 percent), transportation (41 percent), and utility assistance (28 percent). Of those screened, 18 percent were eligible for community navigation services, and 76 percent of eligible beneficiaries accepted the navigation assistance.

The AHC 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 Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. The participants in the AHC Model include urban and rural communities and a variety of care settings, ranging from hospitals to primary care to behavioral health providers, with a shared commitment to addressing health-related social needs and connecting beneficiaries to community resources.   

The fact sheet provides information on how the model is implemented and a snapshot of data on demographics of beneficiaries participating in the model as well as their self-reported health-related social needs. The first AHC Model evaluation report is anticipated in 2021 and will include a more in-depth analysis of data from the AHC Model. This fact sheet is for informational purposes only. Learn more in the AHC Model Fact Sheet: First 750,000 Completed Screenings.