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Related Experiment Video

Updated: Jul 30, 2025

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data
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Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities.

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Summary
This summary is machine-generated.

The Accountable Health Communities (AHC) Model aimed to address social needs for Medicare and Medicaid beneficiaries. Navigation services did not significantly improve community service connections or needs resolution, suggesting a need for increased resources.

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Area of Science:

  • Health Services Research
  • Social Determinants of Health
  • Healthcare Policy

Background:

  • The Center for Medicare and Medicaid Innovation (CMMI) introduced the Accountable Health Communities (AHC) Model in 2017.
  • The model's objective was to evaluate if addressing health-related social needs (HRSN) impacts healthcare utilization and spending among Medicare and Medicaid beneficiaries.

Purpose of the Study:

  • To assess the effectiveness of navigation services in connecting beneficiaries with community services.
  • To determine if these services led to the resolution of beneficiaries' identified health-related social needs.

Main Methods:

  • Surveyed a subset of AHC Model beneficiaries with HRSN and multiple emergency department visits.
  • Employed a randomized control group for comparison.
  • Conducted interviews with AHC Model staff, community service providers, and beneficiaries.

Main Results:

  • Navigation did not significantly increase the rate of connections to community service providers.
  • Navigation did not significantly improve the rate of needs resolution compared to the control group.
  • Identified challenges in connecting beneficiaries and insufficient resources to resolve needs.

Conclusions:

  • Navigation alone may not be sufficient to address health-related social needs effectively.
  • Additional investments in community resources are likely necessary for successful navigation and needs resolution.
  • The AHC Model highlights the complexities of integrating social needs support into healthcare delivery.