The Center for Medicare and Medicaid Innovation (CMMI) released the third and final evaluation report for the Accountable Health Communities (AHC) Model in November 2024. The evaluation found that providing navigation services to address health-related social needs (HRSNs) was associated with reduced emergency department (ED) visits, inpatient admissions, and total care expenditures among participating Medicare and Medicaid beneficiaries.
The national assessment included data from more than one million individuals in 28 communities, contributing robust real-world evidence toward the strategy of social needs screening and navigation in healthcare settings. This aligns with the Camden Coalition’s values and commitment to addressing social needs, as shown by our role in leading AHC Model navigation in South Jersey.
But the evaluation also raised new questions in its findings. Despite lower rates of hospital visits and lower spending among patients with HRSNs who received navigation, their connections to community services and rates of social need resolution weren’t improved.
These mixed findings — as well as insights into the design, execution, and future applications of the AHC Model — were the basis of the Camden Coalition’s national webinar, “The ROI of resource navigation: Findings from the Accountable Health Communities Model,” hosted on January 21. The hour-long panel discussion featured perspectives from a diverse group of experts:
- Moderator Kathleen Noonan, CEO and President of the Camden Coalition
- Dawn Alley, former Chief Strategy Officer at CMMI and Head of Scale at IMPaCT Care
- Marisol Caban, Associate Director of Care Management Initiatives at the Camden Coalition
- Dawn Wiest, Director of Research and Evaluation at the Camden Coalition
Although there are many areas of uncertainty for the future of HRSN screening and navigation in Medicare and Medicaid – from unanswered research questions to the changing political environment – our panel identified key takeaways from the November evaluation report.
Here are the 5 takeaways from the AHC Model evaluation report, relevant to care providers, payers, policymakers, and other community-based care stakeholders.
The model worked – in unexpected ways
The analysis showed that navigation in individuals with social resource needs reduced total cost of care by 3% in Medicaid (or $54 per beneficiary per month) and 4% in Medicare ($116 per beneficiary per month). The Model also reduced hospital stays and ED visits among all beneficiaries and particularly benefited historically marginalized populations. Black and Hispanic beneficiaries were 20% and 19% more likely, respectively, to accept navigation services, and reported a higher rate of resolving their social-related needs — 4% and 11% greater than the rest of the population, respectively.
However, the AHC Model did not significantly improve the proportion of beneficiaries using community services after receiving navigation intervention, nor did it improve the rate of beneficiaries who resolved their HRSNs. The findings raise questions as to which components of the Model drove the outcomes.
“A very intriguing aspect of these findings is that these improvements occurred even with a modest 40% (social) need resolution rate,” Dawn Wiest said during the webinar. “And this suggests potential mechanisms that are worth exploring further, including the possibility that navigation support itself, beyond just needs resolution, plays a meaningful role during implementation.”
It’s critical to better understand what makes navigation programs effective for the individuals who are already more difficult to engage, Dawn Wiest explained. Many of the Camden Coalition’s complex care strategies and programs — including Housing First, the Medical-Legal Partnership, and Pledge to Connect — were informed by secondary analyses from our randomized controlled trial that showed that housing instability, criminal justice involvement, and behavioral health complexities are each associated with lower engagement in care management programs.
“Rather than seeing this as a reason to exclude individuals from care at the Camden Coalition, we’ve used these insights to strengthen our approach to engagement and to expand our service offerings,” Dawn Wiest said.
Navigation services were adaptable, and we went beyond addressing specific resource needs
The model conceptualized navigation as helping beneficiaries overcome barriers to accessing the services they need in response to a screening questionnaire that addressed five key health-related social needs: food insecurity, housing instability, interpersonal violence, transportation problems, and utility difficulties.
In practice, many sites moved beyond navigation to provide a variety of supports, often by community health workers. Community health workers (CHWs) are trustworthy individuals who share life experiences with the people they serve and have firsthand knowledge of the causes and impacts of poor health. In best practice models, CHWs provide social support, health coaching, navigation, and advocacy for community members.
As the lead for AHC Model screening and navigation in South Jersey, the Camden Coalition established screening practices at nearly 50 partner sites in the region and led training among internal and partnership staff on an adapted version of our COACH participant engagement framework. Particularly, Marisol explained, the South Jersey AHC Model navigation strategy emphasized the COACH techniques of “observing the normal routine” and “connecting tasks with vision and priorities.” The result was a tailored navigation process that generated qualitative data and inspired resources that improved the workflow between external CHWs and care team members at each participating facility.
The process also proved highly adaptive in the wake of the COVID pandemic, which threatened to disrupt the Model’s progress. Marisol and colleagues largely shifted CHW screening and navigation processes to remote, telephonic settings — and the outcome did not suffer from the change.
“We recognized that we could develop true therapeutic relationships (during the pandemic),” Marisol said. “The telephonic model became a lifeline. It allowed many people to obtain information and resources at a time when they needed them. AHC just happened to seamlessly coincide with that.”
Marisol’s team also observed a trend that was consistent with qualitative feedback she collected from patients’ bedsides during the Camden Coalition’s RCT findings years ago: many beneficiaries wanted to discuss HRSN with a CHW. And not every HRSN fits into the confines of the five categories identified in the AHC Model.
Marisol described a patient called “Frank” who screened positive for housing and transportation needs in the Model. Frank’s real issue was employment instability due to a felony record and lack of transportation, which thereby affected his housing. His CHW connected him with a job coaching program through Hispanic Family Center, a resource that Frank, a Black man, was not even aware would be available to him. The program helped him find stable employment that provided transportation as part of the position. The success Frank achieved through the CHW navigation motivated him to focus on saving money to buy his own car and find stable housing. Though he was now significantly more likely to resolve his social needs because of the early assistance of CHW navigation, those long-term outcomes are not quantified in Model evaluation.
Many success stories from navigators followed this trend and are consistent with the outcomes from evidence-based CHW programs including IMPaCT Care. IMPaCT has demonstrated in multiple randomized-controlled trials that a person-centered process that goes beyond the checklist can achieve significant results – including a 34% reduction in hospital days. This parallels a qualitative finding from the AHC Model evaluation, which was that problem-solving was a key element of CHWs’ work that made a difference for their clients.
Similar findings were also observed in the Camden Coalition’s secondary analysis of the Camden Core Model randomized controlled trial (RCT), showing that Core Model care management intervention of post-discharge support, ambulatory care coordination, and navigation to health-related social needs resulted in a 15 percent-point increase in primary and specialty outpatient visits within 14 days of discharge among individuals with high hospital use. It also showed a 12.4 percent-point increase in proportion of high-use individuals who received any durable medical equipment within 180 days of discharge.
Feedback from the Model may inform more effective community-based programs
As Dawn Wiest noted, many effective complex care programs and resources are informed by the results of assessment from other interventions — what are the consistent demographics and characteristics that make an individual less likely to engage with community services, and how can we fix that?
The Model showed that, in general, individuals with behavioral health issues were significantly less likely to achieve resolution of social needs than those without: a 20% drop among beneficiaries with substance use disorder and a 4% drop among those with depression. Whether this may be due to the Model’s design, gaps in resourcing, stigma, or other factors is yet to be determined by the ongoing CMMI evaluations. But the findings may inform implementable community-based interventions to address the gap in HRSN resolution.
From the Camden Coalition’s navigation in the Model, we can derive that beneficiaries receiving care at substance use clinics may benefit from a CHW and attorney dyad to address their HRSN.
The evaluation noted that other bridge organizations and participant navigators became advocates for regional and state policy changes that were informed by their involvement — legislation that would address meal programs for children and senior citizens, increased affordable housing stock, and prevention of discrimination against beneficiaries with Section 8 housing vouchers, among other actions. Other Model participants worked directly with local partners to improve the overall access to community services that address HRSN.
“These questions aren’t just about improving navigation programs,” Dawn Wiest said. “They’re about building a healthcare system that can effectively engage and support individuals with complex needs, including those who are traditionally the hardest to reach.”
We need to understand what worked – and what didn’t
The Model demonstrated the impact of navigation, but evaluation hasn’t yet definitively shown what elements of navigation made it successful.
Additionally, because the Model only included individuals who participated in screening, we are unable to determine the value of screening itself. Some people who might benefit from CHWs may not be connected to the healthcare system or may not complete screening. Further, just because someone screens positive for a HRSN doesn’t mean that it is their highest priority or the greatest barrier to their health. IMPaCT research found that only 15% of people named a resource need as their highest priority.
The Model’s five-category HRSN screening tool was designed to satisfy an evaluation need, not to become the standard of initiating navigated care with beneficiaries. So, what would the standard-of-care approach look like if informed by the AHC Model findings?
Infrastructure is key to future success
Approximately two of every five Americans receive their insurance through Medicare, Medicaid, or a Marketplace plan. CMS has had a commitment to ensuring high-quality, high-value care for those populations across administrations. We anticipate that the next four years will include a continued emphasis on accountable care and population health, likely prioritizing health plan and provider flexibility over requirements.
Value-based services that deliver a return on investment such as the AHC Model’s resource screening and navigation should be more accessible to providers and their patients. There are opportunities for CMS to build upon lessons from the AHC findings to make the new Medicare codes even more effective through flexibilities like allowing accountable care organizations to waive copays for vital resources — a major barrier to high-value care among beneficiaries with HRSN. Another flexibility that would increase access would be to allow beneficiaries attributed to an ACO to receive navigation services without initiating a clinical visit. Many effective CHW interventions are not initiated during clinician visits, but those visits are required in the current Medicare regulatory structure.
The AHC evaluation adds to a growing body of research demonstrating the power of person-centered navigation to move the needle on outcomes that matter to patients and the healthcare system. Investments in these programs are an opportunity to realign a healthcare system focused on clinical care to one that provides whole-person care, better serves communities, and delivers real value.
