Funded by the Centers for Medicare & Medicaid Services, the UK Center for Health Services Research has designed the Kentucky Consortium for Accountable Health Communities (KC-AHC) to address the health-related social needs of the most vulnerable community-dwelling beneficiaries across 27 counties in Appalachia. Health-related social needs, such as food insecurity, inadequate or unstable housing and interpersonal violence, increase the risk of developing chronic conditions and reduce individuals’ ability to manage these conditions. They are also associated with increased emergency department visits and inpatient hospital admissions.
The Accountable Health Communities model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. This model includes the following elements: (1) screening of community-dwelling beneficiaries to identify certain unmet health-related social needs; (2) referral of community-dwelling beneficiaries to increase awareness of community services; (3) provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and (4) encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.
KC-AHC Target Counties