The Center for Medicare and Medicaid Innovation (CCMI) released the third and final evaluation report of the Accountable Health Communities (AHC) Model in November 2024. The AHC Model was a large-scale experiment to see whether screening Medicaid and Medicare beneficiaries in healthcare settings for social needs and connecting them to resources through community health worker (CHW) navigators resulted in improved health outcomes and reduced healthcare costs.

The findings, which included data from one million-plus individuals from 28 communities across the country, showed that the Model reduced emergency department (ED) visits, inpatient admissions, and total Medicaid and Medicare expenditures for patients who received screening and navigation services. However, the CMMI investigators did not observe significantly improved connections to community services nor resolution of social needs among these individuals.

The mixed findings will be a leading topic in the Camden Coalition’s national webinar, “The ROI of resource navigation: Findings from the Accountable Health Communities Model,” scheduled for Tuesday, January 21, from 1 – 2 pm ET. Our panel will feature Camden Coalition’s Marisol Caban, who oversaw the AHC Model navigation process in South Jersey, and Dawn Wiest, who led data analysis for the South Jersey AHC site, and will also explore the development and implementation of the Model throughout the U.S. with Dawn Alley, Head of Scale at IMPaCT Care, and former CMMI Chief Strategy Officer.  The conversation will be moderated by Camden Coalition President & CEO, Kathleen Noonan.

Leading into the webinar, we spoke with a trio of Camden Coalition community health workers (CHWs) who coordinated screening and resource referral for patients identified in the AHC Model rollout here in South Jersey: Ashley Serrano, Brittney Paulino, and Melissa Zambrana.

Along with reflecting on the AHC Model experience and their takeaways from the navigation process, the CHWs also shared success stories from their work, their professional development after working in the program, and their advice for peers who may eventually play a similar navigation role.

Click here to register for our national webinar on January 21, featuring Camden Coalition’s Marisol Caban, CEO and President Kathleen Noonan, Director of Research and Evaluation Dawn Wiest, and former CMMI Chief Strategy Officer Dawn Alley, Head of Scale at IMPaCT Care. 

What was your experience, if any, in healthcare or social services before starting in the AHC community health worker role? What attracted you to it?

Ashley: I’ve always had an interest in helping people. Before I started working at the Camden Coalition, I worked at a senior living care center. I started off in the kitchen. I would feed them. If they needed to be bathed, I bathed them. And then I transitioned over to transportation, where I would pick them up from their home and take them to the center or to appointments. I’m also bilingual, so if they needed a translator, I would go with them and assist with that.

Brittney: I actually didn’t have a background in social services or community healthcare. I used to be in customer service before I got hired. I worked in retail — and maybe that’s why they thought I would be suitable for the job. I’m also bilingual, which was important to the role. Now that I’m in it, I love it.

Melissa: I did not have any healthcare or social services experiences prior to working here. What attracted me to it the most was my passion for helping people. I worked 13 years at a hotel as a customer service associate at the front desk. We shut down during COVID, I was on unemployment for a couple months, and then I found this opportunity.

What was your specific role in the rollout of the AHC Model in South Jersey?

Ashley: I was an AHC screener. I started working remotely for the first year in 2021 and then once we came back into the office, I started working at Cooper [University Health Care]. I was conducting in-person screenings — asking people what were their social barriers, if they had any, and how we were able to help them with them.

Brittney: I was conducting interviews with patients at Cooper, and then it would be my responsibility to send them to the community health workers who would then triage them. There were certain qualifications each patient had to meet, including multiple ED admissions over a short period of time. So, I started with that part-time, then I worked my way to a full-time position, and in 2024, I became a certified community health worker.

I remember when I was doing hospital work at Cooper, I just wanted to be more hands-on. I really saw the need in the community. I wanted to give the patients all the resources I could.

Melissa: I was a screener. I would screen members of the community for their health and social needs. I would ask them about how many times they have visited the ED or were an inpatient at the hospital, what chronic conditions have they been diagnosed [with], what are their housing, food access and transportation situations — anything to do with their current needs. I would make about 20 – 30 calls per day, give or take depending on how many people would speak with me.

Are there any moments or stories that stand out from your time doing AHC navigation?

Ashley: There has been a lot. Some of my favorite moments were when [I was] able to help pregnant women with their social barriers. We had vouchers available for those who were experiencing homelessness, and so, we were able to house a few of them.

Brittney: I remember something called Food Bucks [from The Food Trust]. People really liked it. With Camden being a food desert — not having a lot of fresh vegetables, fruits, and healthy produce options — and most food banks only providing canned goods, a lot of residents rely on affordable, processed foods that they don’t need transportation to get to. But with Food Bucks, they would give you 60 “bucks” per household member every month. And with that, you would be able to go to certain corner stores and grocery stores nearby [to buy produce].

Melissa: There are many moments. But the one that stands out the most is the time I helped two sisters who lived in Camden County during the pandemic. They both had their own health and social needs, but one of the sisters was a little bit more in need. She was behind on her mortgage and she had a lot of mental health issues going on. So, it was hard to get her on the right track because mentally, she just wasn’t prepared to do anything. So, we started with helping her mental health. And then once she was at a place where she can tackle everything else, we were able to tackle her housing situation easily. She was more confident by the end of her care that she could take care of her other social needs.

Her sister didn’t have housing needs, but she had food needs — but that’s still a big issue, because many people don’t qualify for food stamps because of how much they earn, but then they don’t have enough to pay their bills and buy groceries as well.

What is your role now?

Ashley: I am an Executive Coordinator with the Camden Coalition. I’m working underneath our CEO [Kathleen Noonan]. I manage different executives’ calendars, attending appointments and meetings with them, and assisting with their communications.

Brittney: I’m a Community Health Worker and Behavioral Health Navigator. It’s kind of the same work. I will get my patients sent from Cooper through our [Health Information Exchange]. These are people leaving the ED who screened for behavioral health issues. I address the lower-risk patients — those with depression and/or anxiety — and I refer them to counseling nearby or regular resources like transportation, food, or utilities, similar to my work with the AHC Model.

Melissa: I’m a certified Community Health Worker. I now work with the Camden Coalition’s eviction prevention program. For that program, I’m mostly helping them with eviction-related needs. If they do have other needs, I let them know to reach out if they need any other support. But 9 times out of 10, they don’t reach out because they’re usually good with everything else. And after AHC, I was able to apply the skills and learnings from that model in non-healthcare settings. I conducted screening and navigation for KIPP schools, assisting parents with social barriers, as well as at Cathedral Kitchen [in Camden], where we facilitated the purchase of items for members.

How has the AHC Model shifted your mindset and approach to community health work in general?

Ashley:  It has helped me to see things differently. A lot of people do have social barriers, especially our Hispanic community. Speaking Spanish, I know there’s a lot of hurdles with everyday tasks like when you go to appointments. A lot of our community members don’t speak English, so it’s harder for them to get things done day-to-day without a translator available. They sometimes needed encouragement to get things done independently, despite that language barrier. It has a big impact on them.

Brittney: It helped me become a lot more compassionate and patient, especially with the work that I do now. Behavioral health issues can get in the way for individuals to attend doctor’s appointments and receive necessary care. Most of them will not tell you everything over the phone. So, you had to think about those things or about those barriers that they’re not sharing with you.

Melissa: Being a part of the AHC Model helped me see the huge need in the community. And to be part of an organization that helps and empowers that community is definitely a great opportunity.

Is there anything you learned from being an AHC navigator that you’ve continued using in your current role?

Ashley: I’ve learned a lot. I have always been a very understanding person, and this has really helped me to love the work I do. To be able to help others is just a big thing for me.

Brittney: I learned how to catch the signs of burnout and how to avoid letting myself get to that stage. With this patient-facing work, even those over-the-phone interactions, it could be easy to slip into the sense of seeing them as a number — especially if they’re not following up with their appointments and making things more difficult.

Melissa: Definitely the resources. I use My Resource Pal [the Camden Coalition’s instance of Findhelp] everywhere I go. I’ve connected with people seeking help on platforms like Facebook that I have shared it with. Just being able to share resources that I have come across from helping people is so rewarding.

For your peers who are not yet implementing nor have been involved with the AHC Model, what is your advice to optimize its benefit?

Ashley: My Resource Pal has been a big help. And you can use it both in English or Spanish, which is really cool especially here in a community where there is a lot of Spanish-speaking people.

I would also just tell them to stay positive, because that’s all there is to it.

Brittney: There’s a tool that we use [in South Jersey] called My Resource Pal,* which is where we got essentially all our resources from. Sometimes we would venture out if we couldn’t find the right options on there, but My Resource Pal has a lot of resources, and I think everyone should be using it in this work. You just put in your zip code and the resource that you need — utilities, transportation, food, things like that — and it will give you everything that’s near you, which is awesome especially for people in our community where they don’t have transportation or don’t want to walk far.

Melissa: Get to know your community programs and resources that are out there, because you never really know who you’re going to encounter and if they’re going to need your assistance. Someone is always in some kind of need. And you might be able to be that help and get them what they need in that particular moment.

*My Resource Pal is a South Jersey-specific resource powered by FindHelp, a national online source for free or reduced-cost resources for those in need.