The Centers for Medicare & Medicaid Services (CMS) Grant Awardee
In April 2017, we were awarded funding for the Accountable Health Communities (AHC) project from the Centers for Medicare & Medicaid Services. The $4.51 million cooperative agreement will be delivered over a five-year period. The AHC model has three goals:
- Help Medicare and Medicaid beneficiaries with unmet health-related social needs connect with community resources through screening, referral, and navigation services.
- Optimize community capacity to address health-related social needs through quality improvement, data-driven decision making, and coordination and alignment of community-based resources.
- Reduce inpatient and outpatient health care use and total costs by addressing unmet health-related social needs through referral and connection to community services.
The project will serve all Medicare and Medicaid beneficiaries living in Kent County who complete a screening at one of the partner sites, and who have unmet health-related social needs. Key areas of focus include housing instability, food insecurity, utility needs, interpersonal violence, and transportation.