Accountable Health Communities

Social needs screening and navigation in South Jersey

Care management & redesign Strengthening ecosystems of care

Transforming whole person care in our region

In 2017, the Camden Coalition was one of 32 local hubs across the country selected to launch the development and testing of the Accountable Health Communities model. A five-year initiative of the Center for Medicare & Medicaid Innovation, Accountable Health Communities aimed to bridge the gap between clinical and community service providers by addressing the following health-related social needs of Medicare and Medicaid beneficiaries: housing instability, food insecurity, utility needs, interpersonal violence, and transportation.

The Camden Coalition’s Accountable Health Communities model focused on the needs of Medicare and Medicaid beneficiaries living in Camden, Burlington, and Gloucester counties who sought healthcare services at participating clinical delivery sites. Our clinical delivery site partners were Cooper University Health Care, Jefferson Health, Virtua Health, CAMcare, and Oaks Integrated Care.

The Camden Coalition, through partnerships with clinical and community service providers serving these counties, implemented four key elements of the Accountable Health Communities model:

  • Screening;
  • Referral;
  • Community navigation services; and
  • Regional partner alignment.

By systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries with participating providers, we sought to reduce healthcare costs and utilization, and improve the health of all patients across these three counties.

Read more about the Accountable Health Communities model or access the Privacy Act Notice for AHC in English and Spanish

*The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS 1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.