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Ready to Launch – Bridge Organizations Selected to Create Clinical-Community Linkages


Email Alert

April 14, 2017

By Rupa Lloyd*

In January 2016, the Department of Health and Human Services announced funding opportunities of up to $157 million to test whether patients’ health can be improved by addressing their social needs. Requests for response to Funding Opportunity Announcements (FOA) were posted through Participants were selected based on the following programmatic factors (as defined in the FOA)1:

  • Recommendations of the objective review panel;
  • Geographic diversity of applicants;
  • Applicants’ readiness to conduct the Accountable Health Communities (AHC) intervention;
  • Scope of impact in the geographic target area;
  • Responsiveness to the Centers for Medicare & Medicaid Services’ (CMS’) inquiries and clarifications to their application;
  • Reviews for programmatic grants management; and
  • Reasonableness of the estimated cost to the government and anticipated costs.

The AHC Model is authorized through the establishment of the Innovation Center under Section 1115A of the Social Security Act.2 This model seeks to test three different service delivery approaches (tracks), each of which are aimed at addressing critical gaps in the current health care delivery system by connecting patients with community services that may address their societal needs (i.e., housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs), which often interfere with meeting their health care needs.

Testing of these models is critical as providers grapple with the challenges of adapting to value-based payments when faced with patient populations with unmet social needs that can impact health outcomes regardless of the quality of care received. Resolving this dichotomy is dependent on finding ways to address these social needs that underlie some of the disparities in health outcomes.

Now these test pilots are about to take-off, with CMS announcing on April 6 that it has selected 32 participants for two of the three available tracks under this AHC Model initiative.3 Participants are known as “bridge organizations” as their function will be to serve as a “hub” to bridge the gap between patients' health care needs, and unmet social needs.

The three tracks are as follows:

  • Awareness Track. Seeks to increase beneficiary awareness of available community services through information dissemination and referral.
  • Assistance Track. Seeks to provide community service navigation services to assist high-risk beneficiaries with accessing services to address health-related social needs.
  • Alignment Track. Seeks to encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries.

The 12 participants selected for the Assistance Track, and the 20 participants selected for the Alignment Track can be found here. Participants will receive funding for infrastructure and staffing needs over a five-year period, to support those bridge organizations that are selected as participants for each track. The program does not directly or indirectly pay for any of the community services that will be offered through these bridge organizations.4

Applications for the Awareness Track were due by November 2016, and announcement of participants selected are expected Summer 2017.

*We would like to thank Rupa S. Lloyd, JD, LHRM, CPPS (Dell Graham PA, Gainesville, FL) for authoring this email alert. We also would like to thank Heather L. Fields (Reinhart Boerner Van Deuren sc, Milwaukee, WI) and Limo T. Cherian (K&L Gates LLP, Chicago, IL) for reviewing this email alert.


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