CMS Accountable Health Communities Model selects Cincinnati as one of 32 participants to link clinical and community services

CINCINNATI, OH – 21 Apr, 2017 – The Health Collaborative, in partnership with United Way of Greater Cincinnati, has been awarded $4.51 million by the Center for Medicare and Medicaid Innovation’s (CMMI) Accountable Health Communities (AHC) Model to serve as a community “hub” to address health-related social needs of the Greater Cincinnati community.

On April 6, CMS announced the 32 regions focused on reducing avoidable health care utilization, impacting the cost of health care for our community, and improving health and quality of care for Medicare and Medicaid beneficiaries by addressing critical drivers of poor health and high health care costs.

These are often factors that fall outside the clinical care environment. Health-related social needs like substance abuse, housing instability, food insecurity, utility needs, interpersonal violence, and transportation, are critical determinants of health and unnecessary health care utilization and costs, but are often difficult for healthcare providers to address without support.

While most healthcare providers currently screen for certain social risks, all recognize the utility of a more robust, standardized protocol that integrates well within the clinical workflow. It’s here the unique partnership between the United Way of Greater Cincinnati and The Health Collaborative aims to connect the dots.  

As a “bridge organization,” The Health Collaborative will serve as a community “hub” and encourage partner alignment to ensure that community services are available and responsive to the needs of patients in our community. This will include partnering with local clinical delivery sites (e.g., physician practices, behavioral health providers, federally qualified health clinics, and hospitals) to conduct systematic screenings for the health-related social needs determined by CMS (housing, utility assistance, food insecurity, interpersonal violence, and transportation)  and then make referrals to community services that may be able to address the identified health-related social needs; coordinating and connecting high-risk patients to community service providers through community service navigation; and aligning model partners to optimize community capacity to address health-related social needs.

A key component of this partnership is leveraging United Way of Greater Cincinnati’s 211 directory, which includes approximately 2,000 community resources for the four-county region of Hamilton, Clermont, Brown, and Butler along with adjacent counties in Indiana and Kentucky. This directory is available via the 211 telephone line as well as a searchable online database. Categories include: basic needs; consumer services; criminal justice and legal services; education; environment quality; healthcare; income support & employment; individual and family life; mental healthcare and counseling; organizational/community services; support groups; and target populations.

“We have incredible resource providers in Cincinnati with demonstrated strengths in addressing some of the key drivers impacting health in our community. United Way is excited to support this innovative approach to health improvement,” said Rob Reifsnyder, President, United Way of Greater Cincinnati.

Craig Brammer, CEO of The Health Collaborative, says the region’s Collective Impact on Health initiative, Gen-H, was important in identifying Greater Cincinnati as well-positioned to test the AHC model.

“The unique multi-sector partnerships and collaboration established through Gen-H have laid the organizational foundation for AHC,” Brammer said. “The goals and priorities are well-aligned with the AHC model and we look forward to connecting our strong healthcare systems with our community service ecosystem to improving health and healthcare while reducing costs.”

The full list of participants in Cincinnati’s AHC model include the following:

Health Systems:

UC Health


Cincinnati Children’s Hospital Medical Center

The Christ Hospital Health Network

Community Partners

United Way of Greater Cincinnati

Cincinnati – Hamilton County Community Action Agency

Health Care Access Now

Council on Aging of Southwestern Ohio

Talbert House

Cradle Cincinnati

Greater Cincinnati Behavioral Health

Interact For Health

Federally Qualified Health Centers

Crossroad Health Center

Healthcare Connection – Lincoln Heights

HealthSource of Ohio

Primary Health Solutions

City of Cincinnati – Health Centers



State of Ohio Medicaid

Hamilton County Public Health

Warren County Combined Health District  



Molina Healthcare

CMS received applications for the Assistance and Alignment Tracks from a variety of organizations across the country. After a review process, 193 counties in 23 states were chosen to participate in the model. The 32 bridge organizations in the AHC model are diverse —varying in type (e.g., county governments, hospitals, universities, and health departments), size, location, and beneficiary demographics.

The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, 2017 with a five-year performance period.

For more information about the Accountable Health Communities Model, please visit:

About the Health Collaborative:

The Health Collaborative is a non-profit organization that strives to positively impact health status, experience, outcomes, and affordability by fostering a connected system of healthcare and community health through innovation, integration, and informatics in the greater Cincinnati region.

For more information about the Health Collaborative, visit

Media Contact
Company Name: The Health Collaborative
Contact Person: Shannan Schmitt
Phone: 5132475253
Country: United States