Accountable Health Communities (AHC)

What is AHC?

Accountable Health Communities (AHC) is a 5-year grant program funded by the Centers for Medicare and Medicaid Services (CMS). The program aims to connect Medicare and Medicaid beneficiaries with community services that address health-related social needs, including housing instability, food insecurity,utility needs, interpersonal violence, and transportation. Yale New Haven Hospital (YNHH) is one of 32 organizations nationwide to receive an AHC grant from CMS. The hospital has partnered with Project Access-New Haven (PA-NH), Fair Haven Community Health Center (FHCHC), and Cornell Scoot-Hill Health Center (CS-HHC) to implement the program.

PA-NH community health workers (CHWs) play a key role in the program by linking participants with community services to address their health-related social needs.

WHO IS ELIGIBLE?

In order to be eligible, individuals must:

Eligibility

one

Have Medicaid or Medicare insurance (children and adults)

Eligibility

two

Live in Greater New Haven (New Haven, East Haven, West Haven, or Hamden)

Eligibility

three

Have been to the ED at least twice in the past 12 months

Eligibility

four

Not be living in a long term care or correctional facility

How Does

it work?

1.

Patients may encounter AHC screeners in the YNHH adult and pediatric emergency departments (EDs), YNHH primary care centers (PCCs), certain YNHH inpatient units, FHCHC, and CS-HHC. AHC screeners meet with patients to explain the program and complete a brief screening questionnaire about health-related social needs

2.

3.

Participants will then be randomly assigned to one of two groups: 70% will receive navigation from a PA-NH CHW and 30% will only receive the community resource summary (control group)

4.

Participants in the CHW group will be contacted by a PA-NH CHW who will assist them with referrals to community resources and offer guidance and support

FOR MORE INFORMATION, PLEASE CONTACT US

With the Support of Sponsors and Community Partners:

PA-NH provides donated medical services to patients of limited insurance status. Patient Navigators assist patients with appointments and navigation of the health care system. Barriers to access are addressed so that physicians can focus on delivering the highest quality care.