The Accountable Health Community initiative consists of an Accountable Health Community model that will utilize care coordination services and systems navigation through the incorporation of Community Health Workers (CHW). This 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, access to care, and quality of care. The RCCCP will serve as the “Bridge Organization” to coordinate between clinical sites, community-based providers, and non-traditional service providers.
Through the implementation of the AHC model, clients will have the resources and support to address health and health health-related social needs simultaneously, rather than having to prioritize one need over the other. Clients who have unmet health-related social needs generally will not access health care needs due to preoccupation with perceived crisis created from their unmet needs. Using the categorization done by the Centers for Medicare & Medicaid Services (CMS) of HRSNs the barriers in the community have been divided into five major domains: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. Identifying the burden of unmet HRSNs is the critical first step to connecting individuals to resources in their communities that can address those needs and as a result improve health outcomes and access to care.