CMS Addresses Social Determinants of Health


The recent announcement by CMS that it has initiated the Accountable Health Communities (AHC) Model to explicitly address social determinants of health establishes an important new front in achieving better health outcomes. AHC recognizes that social factors outside the purview of the traditional healthcare encounter often significantly impact health outcomes, perhaps even more than the quality of medical care provided.

The AHC model is based on emerging evidence that addressing health-related social needs can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization, which in turn reduces costs. This evidence has led to an emerging trend for healthcare providers and insurers to address social issues previously considered beyond the scope of healthcare.


The AHC program will initially target the following core areas:

  • Housing instability and quality
  • Food insecurity
  • Utility needs
  • Interpersonal violence
  • Transportation needs

And will award 44 cooperative agreements from $1 million up to $4.5 million, depending on whether an organization is classified as Track 1 (Awareness), Track 2 (Assistance), or Track 3 (Alignment).

The funds from the AHC program cannot be used to pay directly for services, such as housing, food, or transportation. Instead, the AHC program will fund care coordination on a grand scale. Grant recipients will work toward facilitating the use of community-based services by eligible populations. At the Track 1 level, organizations will increase awareness of available community resources. At the Track 2 level, organizations will assist high-risk beneficiaries with accessing available services. At the highest Track 3 level, organizations will work to align community resources to make them more responsive to the needs of beneficiaries in the community.

By funding care coordination through the AHC program, CMS is investing in the long-term health outcomes of patients. A strategy that benefits both the individual patients and the communities in which they live.


More information about the Accountable Health Communities Model can be found on the CMS web site at:

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