What Does an Accountable Care Community Look Like?

Blog | August 14, 2018


By Brieanne Lyda-McDonald


With the growing understanding of the important role social determinants of health (SDOH) play in health outcomes, health systems and community stakeholders around the country are collaborating to develop Accountable Care Community (ACC) models. These partnerships between health care, social service agencies, community based organizations (CBOs), community members, payers, and other relevant parties seek to:


  • Link people with social needs (e.g., food, housing, transportation) to services that address those needs, and
  • Understand the root causes of these needs in the community and develop mechaMnisms to address them.


This work is hard, requiring community trust, collaboration, and funding, and there isn’t one cookie-cutter approach. Here are some examples from around the country, and in our own state, of partnerships at different stages of ACC development.


CMS Accountable Health Communities

The Centers for Medicare and Medicaid Services (CMS) is piloting an ACC model called Accountable Health Communities [1]. As part of this program, 31 “hub” organizations are helping communities to develop:


  • Screenings for Medicare and Medicaid beneficiaries to identify unmet health-related social needs
  • Methods to refer people to CBOs to meet those needs
  • Help for people to navigate services they need, and
  • Alignment between clinical and community services.


Hennepin County, MN

The Hennepin Health Accountable Care Organization (ACO) is a partnership between medical providers, the Hennepin County Human Services and Health Department, and a county run health maintenance organization (HMO) that serves Medicare and Medicaid beneficiaries [2]. Along with medical services, ACO enrollees have their care coordinated by an interdisciplinary team of nurses, social workers, and community health workers to address social needs like housing and employment.


Dallas-Fort Worth, TX

Parkland Health and Hospital System is addressing the social needs of their patients and the community as a whole in partnership with multiple community organizations through the Parkland Center for Clinical Innovation. The Center connects the hospital and CBOs with a “data bridge” to address SDOH needs of patients and coordinate communication between all stakeholders involved [3].


Cabarrus County, NC

The Cabarrus Health Alliance is made up of more than 25 community partners with funding from the Cabarrus County government and Atrium Health. The Alliance is addressing health disparities through improved access to healthy foods, community programs and developments to increase physical activity, and increasing healthcare provider knowledge of community resources [4].


North Carolina Health Care Systems

Based in Asheville, NC, Mission Health uses collaborative community health assessments completed by the health department, hospital, and community stakeholders to help drive their local health priorities. Their investment in the issues of homelessness and food insecurity are based on the community health assessment’s priority of addressing SDOH in the community.


Based in Charlotte, NC, Atrium Health is collaborating with an organization called Aunt Bertha to assess patients’ SDOH needs and connect them with community resource to meet those needs. They are also collaborating with CBOs like the YMCA and Loaves & Fishes to create programs that reduce juvenile crime and address food insecurity in the community.


There is a wide range of models that can take form as communities seek to develop partnerships to address residents’ social needs. Collaborations will vary from one community to another based on needs and resources available.



[1] Centers for Medicare & Medicaid Services. Accountable Health Communities Model. https://innovation.cms.gov/initiatives/ahcm/

[2] Weigel, P, Finegan, C, Richgels, J. Accountable Care Communities in Rural: Laying the Groundwork in Humboldt County, California. Rural Policy Research Institute. March 2015. http://www.rupri.org/wp-content/uploads/2014/09/Accountable-Care-Communities-in-Rural-Laying-the-Groundwork-in-Humboldt-County-3.pdf

[3] PCCI. Connected Communities of Care. https://pccinnovation.org/connected-communities-of-care/

[4] Cabarrus Health Alliance. Racial and Ethnic Approaches to Community Health (REACH). https://www.cabarrushealth.org/336/REACH