Accountable Health Communities (AHC) Project

The Accountable Health Communities Model addresses a gap between clinical care and community services. It highlights the importance of consumer navigation through the health care process. West Virginia (WV) received one of the Health Care Innovation Awards under the leadership of Partners In Health. This project is a CMS-funded randomized controlled trial to examine the benefits of providing patient navigation services to address social service needs. The purpose of the initiative is to provide a bridge of coordinated care that would link individuals’ medical homes with social service providers so that their social service needs are resolved, and they are able to respond to medical treatment and advice.

The WVU CED and School of Public Health are providing the patient navigator teams to connect consumers directly with social service providers.

What We Do:

Partners in Health screeners interview Medicaid and Medicare beneficiaries who are receiving health care at participating clinical delivery sites. The screeners determine if these beneficiaries have a health related social need such as food insecurity, utility needs, transportation needs, disability needs, inadequate or unstable housing, or problems with interpersonal violence. If the beneficiary has a positive screen, they are referred to a patient navigator. The patient navigator utilizes an extensive statewide inventory of social service providers to find resources located near the beneficiary that can assist in resolving their needs. The navigator connects the beneficiary to the appropriate community resources and then follows up weeks later to determine if the needs are being resolved. The navigator enters the data from each case into a tracking system that CMS will use to determine if resolving social needs improves health outcomes. The patient beneficiaries and the clinic delivery sites have been enthusiastic about adding this program to health care. CMS will examine the data that has been collected over a five year period to determine if data supports a benefit to adding navigation for social needs to the health care environment.

For more information, email Lesley Cottrell at

This funding is provided by the Partners in Corporate Health and the US DHHS-Centers for Medicare & Medicaid Services under grant number 1P1CMS3315-61-01-00