Skip to Main Content

RTI uses cookies to offer you the best experience online. By and clicking “accept” on this website, you opt in and you agree to the use of cookies. If you would like to know more about how RTI uses cookies and how to manage them please view our Privacy Policy here. You can “opt out” or change your mind by visiting: http://optout.aboutads.info/. Click “accept” to agree.

Accept
RTI International
  • About
    • Office Locations
    • Executive Leadership
    • Corporate Governance
    • Partner with Us
      • U.S. Government
      • Clients and Funding Agencies
      • Industry and Commercial Clients
      • Foundations and Associations
      • Bilateral Agencies and Multilateral Banks
      • Universities and Academic Research Institutions
      • Suppliers and Small Businesses
    • Commitment to Quality
      • RTI's Client Listening Program
    • Ethics and Human Research Protection
    • Living Our Mission
    • Veteran Opportunities at RTI

    About

  • Practice Areas
    • Health
      • Public Health and Well-Being
      • Health Care Transformation
      • Behavioral Health
      • Health Behavior Change
      • Precision Medicine
      • RTI Health Solutions (RTI-HS)
      • RTI Center for Community Health Evaluation and Economics Research
      • Health Equity
      • RTI Health Advance
    • Transformative Research Unit for Equity​
      • Equity Capacity Building Hub
      • Social and Economic Justice Research Collaborative
      • Narrative Research and Community Engagement Lab
    • Education and Workforce Development
      • Early Childhood
      • K-12 Education
      • Postsecondary Education
      • Career and Adult Education and Workforce Development
      • Education Policy, Systems, and Governance
      • Education Research Methodologies
      • Education Technologies
    • International Development
      • Energy for Development
      • Environment
      • Global Food Security, Agriculture, and Nutrition
      • Global Health
      • International Education
      • Monitoring, Evaluation, Research, Learning, and Adapting (MERLA)
      • Youth and Economic Opportunity
      • Building Resilience Against COVID-19 in Developing Countries
      • Water, Sanitation, and Hygiene (WASH)
      • RTI Center for Governance
    • Climate Change
      • Clean Energy Technology and Renewables
      • Climate Finance
      • Climate Justice and Equity
      • Climate Planning, Preparedness and Resilience
      • Climate Policy
      • Climate Vulnerability, Adaptation, and Mitigation
      • Economic Impacts of Climate Change
    • Water
      • Food-Energy-Water Nexus
      • Water Quality
      • WASH (Water, Sanitation, Hygiene)
      • Water Resources Management
    • Energy Research
      • Carbon Capture and Utilization
      • Biomass Conversion
      • Natural Gas
      • Energy Efficiency
      • Industrial Water
      • Syngas Processing
    • Environmental Sciences
      • Air Quality
      • RTI Center for Water Resources
      • Urban Sustainability
      • Toxics
      • Building Resiliency in the FEW Nexus
      • Climate Change Sciences and Analysis
      • Environmental Policy
      • Environmental Justice
      • Sustainable Materials & Waste Management Solutions
    • Justice Research and Policy
      • RTI Center for Community Safety and Crime Prevention
      • RTI Center for Policing Research and Investigative Science
      • Child Well-Being and Family Strengthening
      • RTI Center for Forensic Sciences
    • Food Security and Agriculture
      • Market Systems Strengthening
      • Food Safety
      • Food and Nutrition
      • Global Food Security, Agriculture, and Nutrition
      • Climate-Smart Agriculture
      • Agricultural Innovation
      • Obesity Prevention
    • Innovation Ecosystems
      • Innovation Advising
      • Innovation for Economic Growth
      • Innovation for Emerging and Developing Economies
      • Innovation for Organizations
      • Research, Technology, and Innovation Policy
      • Technology Acceleration
    • Military Support
      • Military Behavioral Health
      • Military Health and Human Performance
      • Military Sexual Assault, Harassment, and Domestic Violence Prevention
      • Wearable Sensor Technologies
      • Military Health System Transformation

    Practice Areas

  • Services + Capabilities
    • Surveys and Data Collection
      • Survey Design
      • Instrument Development
      • Survey Methodologies
      • Data Collection
      • Establishment Surveys
      • Health Registries
      • Data Analysis and Reporting
      • Research Operations Center
    • Statistics and Data Science
      • Survey Statistics
      • Environmental Statistics
      • Coordinating Centers for Multisite Studies
      • Analysis and Design of Complex Data
      • Biostatistics
      • RTI Center for Data Science
    • Evaluation, Assessment and Analysis
      • Evaluation Design and Execution
      • Advanced Qualitative, Quantitative, and Mixed Methods
      • Evaluation, Monitoring, and Assessment
      • Economic Analysis
      • Evaluating Communication Interventions and Campaigns
      • Evidence Synthesis for Policy and Practice
      • Risk Assessment and Prediction
    • Program Design and Implementation
      • Systems Strengthening and Scaling
      • Capacity Assessment and Building
      • Policy Reform Support
      • Curriculum and Teacher Professional Development
      • Interventions and Prevention Programs
      • Implementation Science
    • Digital Solutions for Social Impact
      • Human-Centered Design of Digital Solutions
      • Digital Product Development
      • Digital Communication Campaigns
      • Digital Data Analytics
    • Research Technologies
      • Survey Technologies
      • Data Management and Decision Support Systems
      • Geospatial Science, Technology, and Visualization
      • ICT for Limited-Resource Settings
      • Mobile Applications
      • Web Applications
      • Bioinformatics
      • Interactive Computing
    • Drug Discovery and Development
      • Medicinal Chemistry
      • Molecular Design and Cheminformatics
      • Behavioral Pharmacology
      • Drug Metabolism and Pharmacokinetics (DMPK)
      • In Vitro Pharmacology, Bioassay Development, and High-Throughput Screening (HTS)
      • Isotope Labeling
      • Regulatory Consulting and Support for Medical Products
    • Analytical Laboratory Sciences
      • Bioanalytical and Toxicology Research
      • Forensic Sciences
      • Physicochemical Characterizations
      • Metabolomics
      • Proficiency Testing and Reference Materials
      • Microbiology
      • Analytical Chemistry and Pharmaceutics
    • Engineering & Technology R&D
      • Biomedical Technologies
      • Decarbonization Sciences
      • Environmental Exposure & Protection
      • Materials & Environment
      • Sustainable Energy Solutions

    Services + Capabilities

  • Centers
    • RTI Center for Advanced Methods Development
    • RTI Center for Communication Science
      • Communication Research
      • Communication Design
      • Communication Delivery
    • RTI Center for Data Science
    • RTI Center for Education Services
      • Teaching and Learning
      • Education Leadership
      • Peer Learning Networks
      • Strategic Consulting
    • RTI Center for Forensic Sciences
    • RTI Center for Global Noncommunicable Diseases
      • Program Financing & Economics for NCDs
      • Health Systems Strengthening for NCDs
      • Communication Science and Behavior Change for NCDs
      • Implementation Science for NCDs
    • RTI GenOmics, Bioinformatics, and Translational Research Center
      • Disability Studies
      • Ethics
      • Newborn Screening
    • RTI Center for Water Resources
      • Water Resources Sectors
      • Water Resources Services
      • Water Resources Tools
    • RTI Center for Governance
    • RTI Global Gender Center
    • North Carolina Center for Optimizing Military Performance
    • NCCU-RTI Center for Applied Research in Environmental Sciences
    • RTI Center for Climate Solutions

    Centers

  • Impact
    • Newsroom
    • Insights Blog
    • Events
    • Publications
    • RTI Press
      • About the RTI Press
      • Instructions for Authors
      • RTI Press Collections
    • Projects
    • Global Reach
      • Asia
      • Eastern Europe and Central Asia
      • RTI International India
      • Africa
      • Middle East and North Africa (MENA)
      • Latin America and the Caribbean (LAC)

    Impact

  • Experts
    • Our Experts
    • In-Depth With Our Experts
    • Related News
    • Experts In the Media
    • RTI Fellow Program

    Experts

  • Emerging Issues
    • COVID-19 Research
    • Artificial Intelligence
    • Global Health Security
    • Cannabis Research
    • Opioid Research
      • Interventions for Opioid Use Disorders
      • Preventing Opioid Misuse and Overdose
      • Treating Opioid Use Disorders
    • Policing Research and Investigative Science
    • Drone Research and Application
    • E-cigarette Research
    • Zika Virus Research
    • Integrated Governance

    Emerging Issues

  • COVID-19 Research + Response
  • Global Reach
  • Insights Blog
  • Newsroom
  • RTI Press
  • Publications
  • Partner With Us
  • Careers
  • Facebook IconTwitter IconInstagram IconYouTube IconLinkedin Icon
Impact

Accountable Health Communities: Advancing Health Equity with Data

  • Home
  • Impact
  • Accountable Health Communities: Advancing Health Equity with Data

Evaluating the Accountable Health Communities Model to test whether connecting people to community resources to address health-related social needs can improve health outcomes and reduce costs

The economic and social conditions in which people are born, grow, work, live, and age are increasingly recognized as important drivers of their health and well-being. These conditions, known as social determinants of health (SDoH), are just as important—if not more so—as clinical care for determining health outcomes. Adverse impacts of SDoH fall disproportionately on racial and ethnic minorities, low-income populations, individuals with limited English proficiency, people with disabilities, and other groups. The COVID-19 pandemic is a stark reminder about the consequences of SDoH for the burdens of illness and death.

Addressing Social Determinants of Health

Addressing SDoH is central to reducing health disparities and increasing health equity. Strategies for addressing SDoH can target underlying community-level social and economic conditions or individual-level health-related social needs (HRSNs), such as food insecurity and housing instability. For both community-level and individual-level strategies, data are critical to

  • Documenting health disparities associated with SDoH
  • Identifying individuals and communities that can benefit most from addressing the adverse impacts of SDoH
  • Designing effective policies and interventions
  • Measuring whether the policies and interventions increase health equity and reduce disparities.

However, the data needed for those strategies, including data to identify and document SDoH, are often lacking. The Accountable Health Communities (AHC) Model is a major Centers for Medicare & Medicaid Services (CMS) initiative that aims to fill this gap. The AHC Model tests whether screening Medicare and Medicaid beneficiaries for HRSNs and using navigators to connect qualified beneficiaries to community resources to address their needs can improve health outcomes and reduce costs. (Qualified beneficiaries have an HRSN and at least two emergency department visits in the year before screening.)

Evaluating the Accountable Health Communities Model

As the evaluator of the AHC Model, RTI International is analyzing rich data from model participants. These data provide information about (1) whether any of the five core HRSNs (i.e., food insecurity, housing instability, transportation problems, utility difficulties, and interpersonal violence) are prevalent among screened Medicare and Medicaid beneficiaries; (2) whether beneficiaries were successfully connected to community resources; and (3) whether their needs were resolved.

We are using a mixed methods evaluation design to

  • Understand how the AHC Model was implemented
  • Assess success in connecting beneficiaries to community resources and resolving their HRSNs
  • Measure impacts on health care utilization and expenditures
  • Understand how implementation and contextual factors are associated with model impacts.

The evaluation draws on various data types and sources—including model participant data, publicly available data to describe community context, fee-for-service claims and Medicare Advantage encounters for Medicare beneficiaries, Transformed Medicaid Statistical Information System (T-MSIS) data for Medicaid beneficiaries, key informant interviews, and beneficiary and organizational surveys. To evaluate health care utilization and expenditure impacts, we are taking advantage of random assignment of beneficiaries to the model intervention in some areas; in other areas, we are using quasi-experimental difference-in-differences analysis.

Understanding the Findings

Our early findings illustrate how data can offer essential insights for addressing the upstream determinants of poor health and ensuring programs target those who can benefit most. For example, the data show that having an HRSN in combination with high emergency department use—but not having an HRSN alone—predicts persistently high health care use and expenditures. Therefore, initiatives that address HRSNs may choose to focus limited resources on those individuals because that is where the greatest opportunity exists for reducing health care utilization and costs.

Medicare Fee-for-Service Expenditures per Beneficiary per Month before by Screening by AHC Eligibility

Medicare Fee-for-Service Expenditures per Beneficiary per Month before by Screening by AHC Eligibility

The data also offer insights about what is required to address the needs of individuals with HRSNs. For example, almost 60% of navigation-eligible Medicare and Medicaid beneficiaries had more than one of the five core HRSNs. Addressing co-occurring HRSNs requires a multipronged approach.

Moving Forward: Using Data to Reduce Disparities

CMS has identified data collection, analysis, and reporting as core components of its health equity framework. Improving data collection, analysis, and reporting on SDoH can provide powerful information to shape actions and policies—especially as the United States moves toward the goal of reducing disparities and advancing health equity.

Learn More

For more about this project, read the complete Accountable Health Communities (AHC) Model Evaluation: First Evaluation Report.

View & Download

Share

Clients

  • Center for Medicare and Medicaid Innovation (CMMI)

Partners

  • Abt Associates
  • Social Interventions Research & Evaluation Network (SIREN) at the University of California San Francisco
  • Inciter

Our Experts

Lucia Rojas Smith
Lucia Rojas Smith Director, Center for Evaluation, Policy and Implementation Research
Susan Haber Director, Center for Health of Populations
Jules Payne
Julianne Payne Research sociologist, Community and Workplace Health

Practice Areas

Health Care Transformation Public Health and Well-Being

Services

Evaluation Design and Execution Evidence Synthesis for Policy and Practice
RTI Logo
Partner With Us
  • US Government
  • Commercial
  • Foundations & Associations
  • Multilateral Donors
  • Universities
  • Suppliers
Site
  • Privacy Policy
  • Security Policy
  • Site Map
  • Terms of Use
  • Accessibility
  • Contact Us
Contact Us
Facebook Icon Twitter Icon Instagram Icon YouTube Icon Linkedin Icon
delivering the promise of science
for global good
RTI Health Solutions RTI Innovation Advisors RTI Health Advance

© 2023 RTI International. RTI International is a trade name of Research Triangle Institute. RTI and the RTI logo are U.S. registered trademarks of Research Triangle Institute.