The ROI of resource navigation: Findings from the Accountable Health Communities Model

In this national webinar, moderated by our President and CEO Kathleen Noonan, we explored the context of the AHC Model. View the webinar recording to gain insights into how the model was developed, what implementation looked like on the ground, and implications of the findings for care providers, payers, and policymakers.

Jan 27, 2025

Care management & redesign Data analysis & integration Strengthening ecosystems of care Measurement & evaluation Policy & advocacy SDOH & health equity Workforce development

In November, the Center for Medicare and Medicaid Innovation (CMMI) released the third and final evaluation report for the Accountable Health Communities (AHC) Model.

AHC was a large-scale experiment in social needs screening and navigation, covering 28 communities and more than 1 million individuals across the country. It tested whether screening Medicaid and Medicare beneficiaries in health settings for social needs and deploying community health worker (CHW) navigators to connect them to resources could improve health outcomes and reduce costs.

Though the national findings showed reductions in emergency department visits, inpatient admissions, and total Medicare and Medicaid expenditures for people who received AHC navigation, they did not show increased connections to community services or resolutions of social needs.

So what happened? Where do we go from here?

In this national webinar, moderated by our President and CEO Kathleen Noonan, we explored the context of the AHC Model. Dawn Alley, former Chief Strategy Officer at CMMI and Head of Scale at IMPaCT Care, alongside the Camden Coalition’s Marisol Caban, who supervised the AHC navigation process in South Jersey, and Dawn Wiest, who led data collection and analysis for the Camden Coalition’s AHC site shared insights into how the model was developed, what implementation looked like on the ground, and implications of the findings for care providers, payers, and policymakers.

Listen to the webinar

View the webinar slides as a PDF

Download the AHC evaluation report

Resources

The Accountable Health Communities Health-Related Social Needs Screening Tool

Organizations can use this tool from the Centers for Medicare & Medicaid Services (CMS) to help providers find out patients’ needs in the 5 core domains that community services can help with:

Housing instability
Food insecurity
Transportation problems
Utility help needs
Interpersonal safety

Download the AHC screening tool

Audience Q&A: Final thoughts from the AHC Model webinar

Throughout the hour-long webinar, “The ROI of resource navigation: Findings from the Accountable Health Communities Model,” in January, our experts deliberated on the Model’s design, delivery through South Jersey, and the implication of its findings. Their responses to the audience questions are transcribed below, with edits made to clarify their statements.

View the audience Q&A on our blog

5 key takeaways from the AHC Model Evaluation

Care providers, payers, policymakers, and other community-based care stakeholders interested in the report can view the 5 takeaways from the AHC Model evaluation report on our blog.

View the 5 key takeaways on our blog

Medicare Payment for Community Health Worker Services Calendar Year 2024 Physician Fee Schedule Final Rule Summary

This summary from IMPaCT Care, referenced during the webinar, was developed for Medicare billing practitioners to order CHI services, delivered by CHWs, to an eligible beneficiary.

View the summary

Guide for evidence-based Medicaid CHW coverage

This toolkit provides model language for state Medicaid leaders and CHW/P/CHR advocates to use as they develop State Plan Amendments and accompanying guidance documents to establish coverage and payment for CHW/P/CHR services.

View the toolkit

Additional CPT code resources can be accessed through the Partnership to Align Social Care.