The Accountable Health Communities Model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.
Screening 100,000 Medicare and Medicaid enrollees for basic social needs (food, housing, transportation, utilities and interpersonal violence) and providing accurate referrals for those needs;
Providing community-based navigation services to individuals who are identified as needing social supports and who also are utilizing emergency health care services; and,
Collectively identifying gaps in basic services in our communities and developing prioritized plans to address those gaps. (WMRHA will lead this efforts and provide support to ensure screening and community navigation is happening in Eagle, Garfield, Pitkin, and Summit counties)