Care Management in Accountable Health Communities

Accountable Health Communities (AHC) represent a federally structured approach to bridging clinical care and the social factors that shape health outcomes, with care management serving as the operational spine connecting both domains. This page covers the definition and regulatory boundaries of care management within the AHC model, explains how the framework functions at the point of service delivery, identifies common deployment scenarios, and outlines the decision boundaries that distinguish AHC-based care management from adjacent models. Understanding this structure is essential for health system administrators, community-based organizations, and care management professionals navigating Centers for Medicare and Medicaid Services (CMS) program requirements.

Definition and scope

The Accountable Health Communities model was established by CMS under the Center for Medicare and Medicaid Innovation (CMMI) as a five-year demonstration model running from 2017 through 2022 (CMS AHC Model Overview). Its core premise is that health-related social needs (HRSNs) — including housing instability, food insecurity, transportation barriers, utility needs, and interpersonal safety — drive a measurable share of avoidable emergency department (ED) utilization and hospital admissions. Care management within this context is specifically oriented toward identifying those needs through standardized screening and connecting beneficiaries to community services, not toward clinical disease management alone.

CMS defined three intervention tracks within AHC, each escalating in care management intensity:

  1. Awareness Track — Distributes information about community services to all Medicare and Medicaid beneficiaries receiving care at a bridge organization (a hospital, Federally Qualified Health Center, or similar site), with no active care management component.
  2. Assistance Track — Adds navigation services for beneficiaries who screen positive for at least one HRSN, with a community health worker or navigator facilitating referrals.
  3. Alignment Track — Introduces active care management and community partner alignment, requiring bridge organizations to work with community service providers to close identified gaps, track referral completion, and conduct follow-up.

The AHC model's scope is explicitly population-level. It encompasses beneficiaries at risk stratification points defined by HRSN screen-positive status, not by diagnosis or chronic condition alone. This differentiates it structurally from condition-specific programs such as chronic disease care management or Medicare's Chronic Care Management (CCM) billing codes under 99490 et seq.

How it works

Bridge organizations at the center of AHC operations deploy a standardized screening instrument — the Accountable Health Communities Health-Related Social Needs Screening Tool — to Medicare and Medicaid beneficiaries presenting at clinical settings. The tool assesses five core HRSN domains across 10 items. CMS published the instrument through CMMI and required its use for Track 2 and Track 3 participants.

The operational sequence for active care management in the Alignment Track follows a defined structure:

  1. Universal screening — All eligible beneficiaries are screened using the standardized tool during a clinical encounter at the bridge organization.
  2. Positive screen identification — Beneficiaries with at least one unmet HRSN are flagged for navigation or care management intervention.
  3. Navigation and referral — A community health worker or navigator connects screen-positive beneficiaries to community service organizations within a maintained community resource inventory.
  4. Referral tracking — Bridge organizations track whether community referrals are accepted and whether services are received, using a data platform compatible with electronic health records.
  5. Community alignment activities — Track 3 organizations convene community partners to address systemic gaps in service capacity — for example, insufficient subsidized housing units relative to identified need.
  6. Outcomes reporting — Bridge organizations submit data on ED visits, hospital admissions, and HRSN resolution rates to CMS for model evaluation.

The social determinants of health in care management framework underlying AHC draws on evidence that the five core HRSN domains account for a substantial portion of preventable acute utilization among high-need Medicare and Medicaid populations. CMMI structured the model to test whether systematic community linkage reduces total cost of care.

Common scenarios

AHC care management is most operationally visible in three recurring deployment contexts.

Federally Qualified Health Center (FQHC) bridge sites: FQHCs serving predominantly Medicaid populations integrate AHC screening into annual wellness visits and chronic care encounters. A navigator embedded at the FQHC receives referrals from providers for patients screening positive for food insecurity and connects them to regional food banks or SNAP enrollment assistance. The navigator logs referral completion in the bridge organization's data system.

Hospital emergency department screening: A safety-net hospital implements universal AHC screening in triage or post-discharge settings. Patients with repeated ED visits who screen positive for housing instability are referred to community housing navigation programs. This scenario intersects with discharge planning and post-acute care workflows and transitional care management protocols, though AHC-specific navigation remains a distinct administrative function.

Integrated behavioral health settings: Community mental health centers serving dual-eligible beneficiaries screen clients for HRSNs as part of intake. Positive screens for interpersonal safety or utility needs are routed to navigators coordinating with domestic violence shelters or Low Income Home Energy Assistance Program (LIHEAP) offices. This scenario overlaps with behavioral health care management but the AHC component remains limited to HRSN navigation rather than clinical care coordination.

Decision boundaries

Understanding where AHC-based care management ends and adjacent models begin prevents operational confusion and billing compliance failures.

AHC navigation vs. clinical care management: AHC navigation (Tracks 2 and 3) is not equivalent to care management as defined under CMS's Chronic Care Management (CCM) or Complex Chronic Care Management (CCCM) billing codes. CCM under CPT 99490 requires a documented care plan, 20 or more minutes of clinical staff time per month, and a minimum of two chronic conditions. AHC navigation has no analogous billing pathway and is funded through CMMI model payments to bridge organizations, not fee-for-service reimbursement. Professionals seeking billing context should reference care management reimbursement and billing.

AHC alignment vs. Accountable Care Organization (ACO) care management: AHC bridge organizations may or may not participate in Medicare Shared Savings Program (MSSP) ACOs. The two models operate under separate CMS frameworks. ACO-based care management, as described at accountable care organizations and care management, focuses on attributed beneficiary populations and total cost of care across the care continuum. AHC focuses specifically on HRSN-driven utilization within defined clinical encounter points.

Track 2 vs. Track 3 intensity: Track 2 organizations are responsible for navigation referrals but not for community capacity building. Track 3 imposes an additional obligation: the bridge organization must actively work to improve community service availability, which involves convening meetings with service providers, identifying service gaps of 10 or more unmet referrals per quarter (per CMS Track 3 requirements), and documenting alignment activities. This distinction carries compliance implications for bridge organizations self-assessing their model obligations.

Personnel operating within AHC programs may hold credentials relevant to case management certification requirements, though CMS does not mandate a specific credential for AHC navigators. Workforce competency expectations vary by bridge organization and are not standardized across the model at the federal level. Broader workforce context is available through resources on care management workforce and staffing.

Privacy obligations under HIPAA apply to all data collected and transmitted through AHC screening processes. Bridge organizations handling beneficiary HRSN data are subject to the same HIPAA and care management privacy requirements governing clinical records, particularly when data is shared with community-based organizations that may not themselves be covered entities.

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