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A Conceptual Framework for Addressing Social Needs Through the Accountable Health Communities Model

NatDoc: National Document
Website Link:
Publicly Available:
Billing and Reimbursement:
CHW role scope of practice, National guidance
Evidence Generation:
ROI and bundled payment successes/challenges
MCO contract language and reimbursement models
Sustainable Financing:​
How to engage and work with Medicaid, Including community-based CHWs, MCO or bundled payment reimbursement models, Documentation of how CHWs can work within care teams
Workforce Development:
CDC expand CHW work into SDOH, Chronic Disease, CHW training programs (not cert.), Data sharing between social services and clinical teams, General other (including mention of “employment practices”), Training- Content modes delivery


Objectives: To present a conceptual framework to address social needs through accountable health programs in the United States.We present our implementation of the Accountable Health Communities (AHC) Model as an example.
Study Design: Conceptual framework and case study.
Methods: Our conceptual framework of the AHC Model is adapted from the UK Rainbow Model of Integrated Care for the US health care context based on current literature. Our approach is further underpinned by Medical Research Council guidance on intervention development stages, recent framework development in intervention coproduction, and quality improvement methods.
Results: Our team used the adapted framework coupled with Medical Resource Council stages for intervention development to create a program scope and sequence. Standard operating procedures and an implementation plan were created and approved by the Center for Medicare and Medicaid Innovation. Implementation was successfully launched at 13 clinical delivery sites and completed screenings of more than 10,000 patients have been done to date.
Conclusions: Our conceptual framework, which we are applying as a bridge organization in the AHC Model, can serve as a model that organizations can use to successfully design interventions to address social needs in clinical care settings in the United States. Further application and testing of the framework are warranted to advance understanding of social needs interventions in the United States.