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Accountable Health Communities
(AHC) Model


Many of the biggest drivers of health and health care costs are beyond the scope of health care alone. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.  Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.  These health-related social needs (HRSN) often are left undetected and unaddressed. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individuals’ ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.  

The Centers for Medicare & Medicaid Services (CMS) are implementing an Accountable Health Communities (AHC) model to address a critical gap between clinical care and community services in the current delivery system. Nevada Primary Care Association (NVPCA) is one of 32 organizations chosen to participate in the model. The AHC model will test whether increased awareness of and access to services addressing health-related social needs will impact total health care costs and improve health and quality of care for Medicare and Medicaid beneficiaries in targeted communities. 


The foundation of the Accountable Health Communities Model is universal, comprehensive screening for health-related social needs of community-dwelling Medicare and Medicaid beneficiaries accessing health care at participating clinical delivery sites. The model aims to identify and address beneficiaries’ health-related social needs in at least the following core areas: 

  • Housing instability and quality,
  • Food insecurity,
  • Utility needs,
  • Interpersonal violence, and
  • Transportation needs beyond medical transportation

Over a multi-year performance period, CMS will implement and test the model based on promising service delivery approaches: 

  • Assistance Track: Provide community service navigation services to assist high-risk beneficiaries with accessing services
  • Alignment Track: Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

What's Next

NVPCA is funded to serve as a bridge organization to implement the Assistance Track of the AHC Model.  More detail is available through the following links: