New AHC Model Supports Better Care, Smarter Spending & Healthier People

The Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI) recently announced the Accountable Health Communities (AHC) Model, which will examine whether systematically identifying and attempting to address health-related social needs of Medicare and Medicaid beneficiaries through referral and community navigation services can impact healthcare costs, reduce inpatient and outpatient healthcare utilization, and improve healthcare quality and delivery.

As Accountable Care Organizations (ACOs), integrated delivery systems, and community-based organizations collaborate on how to best meet the medical and socio-economic needs of our most vulnerable populations, this new grant opportunity is a way to further solidify and strengthen provider partnerships. “The AHC Model will allow providers to leverage the clinical and technology infrastructure they have built and test solutions and interventions for the health-related but unmet social needs such as food insecurity and unstable housing,” said Olga Bronnikova, Senior Legislative & Policy Advisor at Gorman Health Group (GHG).

“Since the time of Hippocrates, physicians have known their patients’ physical health is highly dependent on factors in their physical, economic, and social environment,” said Leslie Mullins, Senior Consultant at GHG. “The World Health Organization (WHO) has described these Social Determinants of Health (SDH) as the conditions in which people are born, grow, work, live, and age, and studies have shown SDH account for 15% to 40% of the variance in health between different groups. The AHC model will directly address how improving the SDH will affect beneficiaries’ healthcare costs and improve health outcomes.

Information about the AHC Model is available at Accountable Health Communities Model web page.

Eligible Participants:

Eligible applicants are community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers. All states are eligible. Medicare Advantage (MA) and Program of All-inclusive Care for the Elderly (PACE) organizations are not eligible to serve as bridge organizations.

Model Details:

The model is a five-year test which will aim to address beneficiaries’ social needs in the following core areas:
• Housing instability and quality,
• Food insecurity,
• Utility needs,
• Interpersonal violence, and
• Transportation needs beyond medical transportation.

The model includes three tracks which will attempt to test the following service delivery approaches:

Track 1 — Awareness: Increasing beneficiary awareness of available community services through information dissemination and referral.

Track 2 — Assistance: Providing community service navigation to assist high-risk beneficiaries with accessing community services to address the identified social needs impacting their total healthcare costs, inpatient and outpatient healthcare utilization, and health and quality of care.

Track 3 — Alignment: Encourage partner alignment to ensure community services are available and responsive to the needs of beneficiaries.

  • The bridge organization is responsible for coordinating community efforts to: Identify and partner with clinical delivery sites and community service providers.
  • Conduct systematic health-related social needs screenings
  • Connect beneficiaries to community resources via referrals for identified unmet health-related social needs.
  • Tracks 2 and 3: Assist beneficiaries with accessing community resources through community service navigation.
  • Track 3: Partner with and align community service partners to optimize community capacity to address health-related social needs.

Bridge organizations are expected to partner with:

  • At least one Medicaid state agency.
  • Clinical delivery sites including at least one of the following: hospital, primary care provider or practice, provider of behavioral health services.

Community service providers who can address the health-related social needs identified through a screening.

Award Information:

Up to $1 million to each bridge organization in Track 1 — Awareness
Up to $2.57 million to each bridge organization in Track 2 — Assistance
Up to $4.51 million to each bridge organization in Track 3 — Alignment

CMS anticipates awards will be made in the fall of 2016. The model period is five years, from January 1, 2017, to December 31, 2021.

CMS will support and fund:
• 12 cooperative agreements for Track 1
• 12 cooperative agreements for Track 2
• 20 cooperative agreements for Track 3

Instructions and Deadlines

Applicants must submit a letter of intent (LOI) to by February 8, 2016. If an LOI is not submitted, any subsequent application will be ineligible. Applications are due by 1:00 p.m. EST on March 31, 2016. Applicants may apply for up to two tracks, but successful applicants will only be selected for one.

At Gorman Health Group (GHG), we have successfully assisted providers in forming ACOs and developing strategies to address the clinical and socio-economic needs of vulnerable populations within our communities.  We are prepared to assist you in your decision-making process for which of the various tracks of the grant application to apply, completion of the grant application, and implementation of your program. As noted above, time is of the essence. Let GHG help bring your innovative care ideas to fruition.

For more information, please contact me directly at



GHG’s multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year’s special! Save 15% using promo code NewYear16 at checkout. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

No Comments Yet

Leave a Reply

Your email address will not be published.