The third evaluation report for the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) Model, released in November 2024, highlights the program’s effort to bridge the gap between clinical care and community services. The AHC Model targeted health-related social needs by integrating systematic screening, referral processes, and community navigation services to improve patient outcomes and reduce healthcare costs.

As an AHC awardee, Health Quality Innovators helped address the unmet social needs of eligible Medicare or Medicaid community members living in the city of Richmond, Virginia and Chesterfield, Hanover and Henrico counties. Through this work, we extended almost 36,000 total offers to screen eligible participants and personally assisted more than 6,000 high-risk individuals by connecting them to resources.

The latest evaluation provides evidence that navigation can enhance care delivery by addressing health-related social barriers and advancing health equity. The AHC model also reduced costs and utilization among non-white and/or Hispanic Medicare FFS beneficiaries.

Learn more about the latest AHC Model findings.