Client: Eligible Medicare or Medicaid community members living in the city of Richmond and surrounding counties of Chesterfield, Hanover and Henrico in Virginia.

Challenge: Unmet social needs can have a greater influence on health than either genetic factors or access to healthcare services. Identifying and addressing factors outside of the clinical setting that impact patients’ health can highlight health inequities and their root causes.

Solution: RVA Community Cares Navigators were trained to assist eligible participants to help them reach health goals and tackle obstacles preventing them from staying healthy. Focusing on five core needs – food, housing, utilities, transportation and safety – navigators connected clients to free or low-cost community resources and services to help sustain long-term success. Navigators also maintained regular contact with clients to address any potential barriers and monitor progress toward meeting goals.

Results: The RVA Community Cares initiative extended almost 36,000 total offers to screen eligible participants over the course of the six-year initiative. The program personally assisted 6,066 high-risk individuals by connecting them to resources.

Sponsor: This project was part of the Accountable Health Communities (AHC) model, which is funded by the Centers for Medicare & Medicaid Services (CMS).

This publication is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $4,484,414 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.