In 2018, the Centers for Medicare and Medicaid granted $157 million dollars to 32 healthcare organizations to support local communities to address the health related social needs of Medicare and Medicaid beneficiaries by bridging the hap between clinical and community service providers.

This is an important initiative as some of the largest drivers of health and healthcare costs fall outside of the health system and clinical care setting. Health related social needs are critical drivers of utilization and cost to the health system and are often difficult for providers to address without the adequate data and support.

Throughout the country, many hospital systems lack the infrastructure and incentives to develop systematic protocols to connect patients with community service providers to address health related social needs.

According to Healthcare IT News, 78% of provider executives say they do not have the data to recognize patient’s social needs. states that the Foundation of the Accountable Health Communities Model is a 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 will test whether systematically identifying and addressing beneficiaries health related social needs impacts total health care costs and reduces inpatient and outpatient utilization.

In an article written in the New England Journal of Medicine, it features Baltimore, Maryland as home to some of the best health care institutions in the country, yet its residents face a mortality rate that is 30% higher than the rest of the country and ranks the city last in nearly all key health outcomes. In addition, more than 1 out of 3 children live below the federal poverty line and more than 30% of Baltimore households earn less than $25,000 per year.

When the CMS grant money came, the Baltimore Accountable Health Community team identified four main strategies for key implementation:

· Identify and scale best practices. The first goal is to develop a unified learning community in which practitioners and administrators can share experiences covering the full spectrum of activities related to addressing patients’ social needs: screening, referral, connection to a resource, and ongoing follow-up back to the referring provider.

· Gain maximum efficiency. Given that patients access different care points, the second goal is to implement a central hub of trained and supervised community health workers that is accessible to any participating provider.

· Enable unified data-insight and technology systems. In order to facilitate the first two goals, the third goal is to establish an integrated technology system that merges with the regional health information exchange to provide care team members insight into a patient’s social needs just as they are able to view clinical information.

· Ensure true community partnership. In partnership with a robust community advisory board, the fourth goal is to track and assess community referral outcomes data in order to (1) develop a quantitative business case for resource connections and (2) determine where additional community advocacy and resources are necessary.

I believe Accountable Health Communities are a promising model to both decrease medical costs and improve health outcomes by placing greater emphasis on addressing social economic issues that ultimately define health. The new health model is one that involves multiple stakeholders working together to improve the health and well being of their communities by addressing social determinants of health. Stakeholders include health care delivery systems, public health organizations and community organizations. The stakeholders commit to share responsibility, resources and data to improve community health indicators.

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  • Michael Leyson, MBA



    The Leyson Report is a Journal focused on Leadership & Innovation Trends in Healthcare. We partner with authentic leaders, solving real problems, offering fresh solutions and focused on integrative leadership capabilities, business innovation, technology and operational excellence to solve the toughest challenges in healthcare.