Accountable Health Communities

The Need

A significant amount of a person’s health is influenced by what happens outside the healthcare setting. Social and environmental factors make up 80% of the factors that determine a person’s health but they are rarely addressed by the health care system.

If people have social service needs – lack of food or housing or utilities – they can’t focus on healthcare outcomes. A person with diabetes, for example, who lives in a home without electricity, will be better able to manage their disease with healthy food in a working refrigerator.

Unmet health-related social needs may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions and increase health care costs.


The Help

Accountable Health Communities bridges the gap between the clinical health care delivery system and community service providers to address health-related social needs.

In May 2017, Greater Cleveland was awarded one of 28 Accountable Health Communities grants by the Centers for Medicare and Medicaid Services’ Innovation Center. The five-year, $4.51 million project pilots a transformative new model of healthcare service provision. The goal of Accountable Health Communities is to determine if addressing health-related social needs positively impacts Medicaid and Medicare beneficiaries, thereby reducing costs while improving quality of life. 

United Way of Greater Cleveland began sending 211 Specialists into seven area hospitals and health clinics to offer low-income patients screening for social service needs such as housing, food, and transportation. Annually, 75,000 patients are offered screenings for social needs at participating clinical sites, and qualifying individuals are enrolled in ongoing Navigation activities with 211. 


United Way of Greater Cleveland serves as the bridge organization for the project, convening local stakeholders to monitor consortium activities and grow local social service system capacity.

Cleveland Clinic: Emergency Departments at Euclid Hospital, Lakewood Family Health Center, Lutheran Hospital, Marymount Hospital, and South Pointe Hospital;

MetroHealth: Ohio City Health Center and Main Campus clinics for Internal Medicine, Cardiology, Pediatrics, and Pre-Natal Care, and Labor & Delivery;

Vincent Charity Medical Center: In-patient Psychiatric Care;

Ohio Department of Medicaid supports federal reporting for effective evaluation;

Better Health Partnership, a regional leader in using data to improve healthcare, advises on project workflow and quality improvement efforts;

Case Western Reserve University Poverty Center analyzes gaps in social services; and

Cuyahoga County Board of Health integrates AHC into their Health Improvement Partnership.

Health Pathways

United Way of Greater Cleveland is funding five Community Hub grants that are tackling issues related to health pathways. Learn more about the agencies and their programs:

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