A recent evaluation of CMS’s Accountable Health Communities (AHC) Model confirmed what many communities have long believed: addressing health-related social needs improves outcomes and lowers costs. The model generated more than $200 million in savings, reduced hospitalizations and avoidable emergency department visits, and helped connect people to critical resources related to housing, food, transportation, utilities, and interpersonal safety.
But behind those results was another important lesson.
The success of the AHC Model was not driven solely by screening tools or referral platforms; it was made possible by trusted, community-based organizations that served as both neutral conveners and technology solution partners, bringing together health care providers, community-based organizations, public health agencies, Medicaid programs, and social service providers around a shared goal.
During a recent Civitas Networks for Health® Collaboratives in Action webinar, leaders from Camden Coalition (Audrey Hendricks, Marisol Caban, and Ashley Humienny), MyHealth Access Network (former CEO and founder, David Kendrick), and Civitas (Karen Ostrowski) shared how their organizations helped operationalize the AHC Model and what implementers of future innovation efforts can learn from their experience.
The Hidden Infrastructure Behind Success
The AHC Model was designed to test whether systematically identifying and addressing health-related social needs could improve health outcomes while lowering costs. While the model itself focused on screening, navigation, and referrals, webinar presenters emphasized that those activities depended on something much larger: community infrastructure.
Organizations like Camden Coalition and MyHealth Access Network served as the connective tissue between sectors that do not traditionally work together. Their role extended far beyond technology implementation. As Camden Coalition’s team described, they worked with nearly 50 partner sites across South Jersey to establish screening practices, redesign workflows, train staff, manage performance, coordinate stakeholders, and build sustainable processes that integrated social needs screening into everyday operations.
In Oklahoma, MyHealth Access Network leveraged its statewide health information exchange (HIE) infrastructure to connect providers, public health departments, community health workers, and community-based organizations through what became known as the Route 66 Coalition.
These organizations served as much more than just data intermediaries – they acted as trusted brokers, problem-solvers, and implementation partners.
Neutral Conveners Create the Conditions for Collaboration
One of the strongest themes that emerged throughout the webinar was the importance of neutral convening.
Camden Coalition described its role as helping providers, community-based organizations, Medicaid stakeholders, public health agencies, and community partners align around shared objectives. Rather than leading from above, the organization focused on creating space for collaboration and helping partners coordinate across organizational boundaries. The Coalition repeatedly emphasized that strong interventions can fail in weak ecosystems. Contracts alone cannot create trust. Referral platforms alone cannot create alignment. Technology alone cannot sustain partnerships. Instead, successful implementation depended on long-standing relationships and the ability to bring together organizations with different priorities, workflows, and capacities.
As presenters noted, every community is different.
Each partner organization has its own staffing model, patient flow, leadership structure, and readiness level. Recognizing those differences and helping stakeholders work through them required a trusted, neutral organization capable of balancing competing needs while maintaining focus on shared outcomes.
Importantly, those relationships became infrastructure in their own right.
“The relationship was not a soft add-on. They were infrastructure,” Camden Coalition shared during the webinar.
Technology Must Fit the Workflow, Not the Other Way Around
Both organizations stressed another critical lesson: implementation begins with understanding workflow. MyHealth Access Network’s experience provided a powerful example. Early in the project, the team conducted a detailed time-and-motion study to understand what traditional screening would require in clinical settings. The results were sobering. Screening patients during visits would take 12 to 15 minutes per patient. Connecting individuals with appropriate referrals would require an additional 20 minutes. For already-burdened clinics and emergency departments, the approach was unsustainable.
Rather than forcing providers to absorb that burden, MyHealth redesigned the process. Using admission, discharge, and transfer (ADT) data feeds available through the HIE, the team created an automated workflow that delivered social needs screenings directly to patients’ mobile devices while they waited for care. Patients completed screenings in just a few minutes. Tailored referrals were automatically generated based on reported needs and geographic location. The result was a scalable solution that dramatically reduced staff burden while increasing reach.
The lesson is clear: technology should adapt to existing workflows, not require providers to overhaul them.
The Value of Being a Technology Solution Partner
Both organizations demonstrated a broader vision of what technology leadership can look like. Rather than simply operating technology platforms, they functioned as solution partners.
Camden Coalition used its HIE infrastructure to support outreach during the COVID-19 pandemic when in-person screening became impossible. Existing encounter notification capabilities were repurposed to enable telephonic outreach workflows. Clinical data were also used to support health equity initiatives, helping identify and prioritize outreach to pregnant and postpartum residents experiencing disparities in birth outcomes.
Similarly, MyHealth Access Network leveraged statewide data infrastructure to deliver targeted screenings, automate referrals, identify individuals eligible for navigation services, and coordinate across multiple programs to reduce duplication and confusion.
In both cases, technology served strategic objectives:
- Improving care coordination
- Supporting health equity efforts
- Reducing provider burden
- Scaling community-based interventions
- Enhancing navigation workflows
- Enabling cross-sector collaboration
Technology became most valuable when paired with inclusive governance, operational expertise, and trusted relationships.
Five (5) Key Lessons for Future Innovation Models
The recent webinar concluded with a discussion about how lessons from the AHC Model are informing a new generation of CMS Innovation Center models.
Several takeaways emerged:
1. There Is No Cookie-Cutter Approach
Communities differ significantly in resources, capabilities, relationships, and readiness levels. Future models must allow flexibility for local adaptation while maintaining alignment with broader goals.
2. Trust Is Infrastructure
Relationships among providers, community organizations, public health agencies, and residents are foundational to successful implementation. Building and maintaining those relationships requires sustained investment.
3. Technology Should Reduce Friction
Successful solutions streamline workflows, automate routine tasks, and place the right information in the hands of the right people at the right time.
4. Shared Data Enables Shared Accountability
Health Information Exchanges, Community Information Exchanges, Health Data Utilities, and similar organizations help ensure stakeholders operate from a common understanding and can coordinate care more effectively by linking robust, high-quality data and providing value-added insights.
5. Community-Based Organizations Need Sustainable Funding
AHC successfully demonstrated the value of navigation, referral coordination, and community partnerships. Future models must establish durable funding mechanisms that support these activities long after pilot funding ends.
What All of This Means for the Future
As CMS launches new payment and care transformation models, many of the assumptions embedded within those initiatives mirror the capabilities demonstrated during the AHC Model. However, the webinarpanelists warned that federal models often assume local infrastructure already exists, which in most cases it does, but it also requires sustainable funding sources.
That reality creates a compelling case for continued investment in health information exchanges, community information exchanges, health data utilities, community care hubs, and other collaborative organizations that serve as both neutral conveners and technology solution partners.
The AHC Model demonstrated that improving health outcomes is not only about identifying needs. It is about building the systems, relationships, governance structures, and technology infrastructure that enable communities to respond effectively.
As one panelist noted, the future role of HIEs and health data collaboratives extends far beyond serving as “data pipes.”
Their greatest value may lie in their unique ability to bridge the worlds of clinical care, public health, behavioral health, and community services, creating the connected ecosystems needed to improve health and well-being for all.
Want to learn more from Civitas members, Camden Coalition and MyHealth Access Network? Watch the recording and view the slides.
