$157 Million Up for Grabs to Meet Patients’ Social Needs

Home health providers are highly aware of how social needs, such as those related to housing quality and transportation, can impact a patient’s wellbeing and drive up health care costs. Many agencies already shoulder the cost of finding social solutions, but now a new government initiative is focusing on the issue and could help defray of this financial burden.

The Accountable Health Communities (AHC) model introduced by The Centers for Medicare & Medicaid Services (CMS) intends to bridge the gap between the social and clinical needs in the current care delivery system with $157 million in potential funding.

The announcement comes as more research underscores that unmet social needs can lead to an increase in chronic conditions, avoidable heath care utilization and higher health care costs.


The model has a specific purpose to address some of the social determinants of health that are costly to the overall system and has big implications for the home health industry, where case management of patients can often include dealing with direct social needs.

The health-related social needs identified by CMS include: housing instability and quality; food insecurity; utility needs; interpersonal violence; and transportation needs beyond medical transportation.

While CMS will not pay for these needs directly, the federal agency will fund 44 cooperative agreements over five years to bridge organizations that will implement the model. CMS has three tracks it hopes to implement and fund over that period of time:


1. Awareness—Increase awareness of available community services through information circulation and referrals to beneficiaries.

2. Assistance—Provide navigation services to communities to assist high-risk beneficiaries access available services.

3. Alignment—Ensure services are available and responsive to the needs of beneficiaries through partner alignment.

The model will test whether the three tracks can have any meaningful impact on reducing health care costs and improving health outcomes.

Community-based organizations, health care practices, hospitals and health systems, higher education institutions, local governments, tribal organizations and for-profit and not-for-profit local and national entities are eligible to apply for the model.

Cooperative agreement awards are anticipated to be announced in Fall 2016, according to CMS.

Written by Amy Baxter

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