Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities

Jeanette Renaud
Sean R. McClellan
Kelli DePriest
Katharine Witgert
Shannon O’Connor
Kate Abowd Johnson
Natalia Barolin
Laura M. Gottlieb
Emilia H. De Marchis
Lucia Rojas-Smith
Susan G. Haber
Peer-Reviewed Article
May 2023
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Barriers to community social services to address health-related social needs persist despite screening and referral programs in clinical settings.


Health-related social needs screening and referral programs aim to increase connections to social service programs and improve overall health outcomes. In the Accountable Health Communities (AHC) Model, patients are screened in clinical delivery settings for key health-related social needs including food insecurity, housing instability, transportation needs, difficulties paying for utilities, and interpersonal violence or safety issues and eligible patients are referred for navigational services for community social service programs. In this study, the authors evaluated the AHC model to examine the extent to which referral and navigation services facilitated patient connection to community services and resolution of their health-related social needs.


The authors examined several data sources including screening and qualitative data from bridge organizations, Medicaid and Medicare enrollment information, and beneficiary survey data. Of the more than one million patients screened, 37% screened positive for at least one health-related social need. The authors found no statistically significant differences in the use of community services between the intervention and control groups. Some barriers to accessing community services included incomplete referral information, difficulty contacting community service providers and an overall insufficiency in community services in meeting patient needs.


This study highlights opportunities to strengthen the community social services infrastructure to better facilitate connection to and use of services for patients with health-related social needs. While the AHC model was successful at engaging patients, building a concrete connection to community services was still difficult and not all patients were able to access services even after navigation supports. This underscores the need for more integrated social and clinical care delivery and support services to better address patients’ health-related social needs.

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