AHC final report shows social needs navigation led to over $200 million in net savings
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In February CMS published the final external evaluation report for the Accountable Health Communities (AHC) Model, in which Medicaid and Medicare beneficiaries who screened positive for at least 1 of 5 social needs were navigated to community resources. Key findings include:
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- The AHC Model decreased total costs by 3% for Medicaid beneficiaries and 4% for Medicare beneficiaries, generating more than $200 million in net savings.
- The model reduced utilization, including:
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Reducing hospitalizations for Medicaid members by 3%,
- Reducing ambulatory-care-sensitive hospitalizations for Medicare members by 8%, and
- Reducing avoidable ED visits by 3% among Medicaid members and by 5% among Medicare beneficiaries.
- Impacts were stronger for Medicaid beneficiaries with multiple needs and for Medicare beneficiaries with transportation needs.
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It is with mixed emotions that we announce that in mid-April, SIREN Co-Director Caroline Fichtenberg will be leaving SIREN to join the California Department of Health Care Services (DHCS) as Evaluation Branch Chief. Over the last nine years, Caroline has been an integral member of our team and a driving force for both transforming healthcare sector strategies to address social care and fostering community-based partnerships to reduce health inequities. We are incredibly grateful to her for a decade of leadership that has left a lasting impact on both the SIREN network and the broader field. Please join us in thanking Caroline and wishing her the very best in her new role!
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Share Our Strength and HealthBegins are launching the third cohort of grant funding for the Medicaid Food Security Partners Program. Four state-based organizations or coalitions will be funded to advance promising food and nutrition security policy initiative(s), with a special focus on strategies that promote SNAP and WIC enrollment among children and families. Applications are due April 17 at 8:59pm PT.
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Webinars
Weill Cornell Medicine: Addressing Drivers of Health: What Works, What Doesn’t, and What’s Next – March 25, 2026 | 1pm PT/4pm ET
The Intersection: Rest & Renewal: An Invitation to Reset and Reconnect – March 25, 2026 | 4pm PT/7pm ET
Systems for Action: The Community-Led Aligning Toolkit – May 6, 2026 | 9am PT/12pm ET
Systems for Action: Aligning Health and Social Systems to Promote Vaccination Access for Populations Experiencing Systemic Barriers – May 20, 2026 | 9am PT/12pm ET
Meetings & Conferences
American Hospital Association: 2026 AHA Annual Membership Meeting
– April 19-21, 2026 | Washington, D.C.
Health Experiences Research Network: Health Experiences Research 1.0 Hybrid Training – May 18-20, 2026 | Albuquerque, NM & virtual
AcademyHealth: 2026 Annual Research Meeting – May 30-June 2, 2026 | Seattle, WA | Early bird registration ends April 3, 2026.
Camden Coalition: Putting Care at the Center 2026 – October 14-16, 2026 | Oakland, CA
NAPCRG: 54th Annual Meeting – November 24-26, 2025 | Toronto, Canada | Call for papers closes April 19, 2026 at 9:59pm PT.
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In our Research Round-Up we share multiple SIREN-relevant articles published since our last newsletter. For a full list, see the SIREN Evidence and Resource Library. As always, if you are aware of resources that you think should be added to the library, please send them our way.
Research Highlight
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Food Security Interventions – Effectiveness Studies
Health Systems Approaches for Advancing Implementation and Policy for Food is Medicine Shah PP, Aggarwal M, Aspry KE, et al. | JAMA Health Forum
A summary of federal and state-level policies for advancing nutrition security and food is medicine.
Influence of a Pediatric Fruit and Vegetable Prescription Program in Flint Michigan on Caregiver Perceptions of Pediatric Health Care Saxe-Custack A, Haggerty D, Shipp G, LaChance J | Preventive Medicine Reports
Use of a $15 produce prescription program was associated with increased caregiver satisfaction of care.
Food is Medicine in Action: Dietary and Food Security Outcomes of a Health Care-Based Community-Supported Agriculture Program Colasanti K, Di Stefano F, Gerhart J, Shores A, Smoger K | Health Promotion Practice
Participants experienced increases in fruit and vegetable intake and household food security.
Food Security Interventions – Implementation Studies
Navigating Food Insecurity: Insights from Families Participating in a Produce Delivery Program Gorecki MC, Anderson CB, Banister A, et al. | Academic Pediatrics
Food Rx + CHW: A Community Health Worker-Led Medically Tailored Grocery Intervention to Address Food Insecurity and Type 2 Diabetes, A Pilot Randomized Trial Bridges KM, Woodward J, Murray M, et al. | BMC Public Health
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Financial Security Interventions
Unconditional Cash Transfers to Improve Health Behaviors Among Primary Care Patients: A Qualitative Sub-Study of a Randomized Clinical Trial Gibson LA, Richterman A, Randall A, et al. | Social Science & Medicine
This qualitative study identified 4 potential pathways through which cash transfers may improve health: 1) temporary reductions in stress and anxiety, 2) changes in diet and physical activity, 3) improved medication adherence, and 4) increased healthcare seeking behavior. Participants in the control group were disappointed not to receive the intervention, but felt the process was fair because all participants were economically vulnerable.
Transportation Security Interventions
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Screening / Awareness
Experiences of Social Risk Screening in the Safety-Net Among Patients with Mental Health Needs Loo SS, Ogden SN, Ospina J, et al. | Journal of General Internal Medicine
This qualitative study found that “asking patients about their social needs further emphasizes their already vulnerable position when seeking medical care, particularly when addressing mental health concerns. Patients stated that they were reluctant to disclose future health-related social needs when prior reported needs were not supported or addressed (“double-loss”).”
Barriers and Facilitators to Screening for Anxiety and Intimate Partner Violence Cantor AG, Barnes C, Likumahuwa-Ackman S, et al. | Journal of the American Board of Family Medicine
The following could improve anxiety and IPV screening practices in primary care: “Workflow diagrams and resource guides responsive to identified screening barriers and facilitators, including clarification of insurance coverage for preventive services, and resources to support implementation of protocols of screening methods, clinical documentation, and referrals for anxiety and IPV.”
Applying a Process Mapping Methodology to Identify Barriers and Facilitators to Social Needs Screener and Medical-Legal Partnership Integration into Primary Care Facilities Graham JD, Kraschnewski J, Allen S, et al. | Journal of Clinical and Translational Science
Facilitators identified: “Review and adaptation of social needs screening (SNS) should be regular; involvement of providers and staff is necessary for SNS integration; cross-disciplinary training, physical space, and information technology is needed to promote MLP; and identification of local resources for social need referrals is critical for provider buy-in.”
Enhancing Outcomes for Geriatric Patients with Evaluation of the Social Determinants of Health Toland M, Winegar R | Geriatric Nursing
A qualitative improvement study increased screening by 70% and SDOH identification by 58% compared to the pre-intervention baseline.
Improving Social Needs Screening in General Paediatrics Through Project SEEK Feeney C, Monroe B, Agbim C, Kamath S, Parente V | BMJ Open Quality
“Rates of screening hospitalized children improved from 0% to 57% after various interventions, including nursing education and feedback, providing meal trays from the cafeteria to families in need, and integrating the screening questionnaire into the electronic health record.”
Medicaid Policy
Amplifying Community Perspectives in Medicaid Policymaking: Findings from North Carolina Debab S, Repka S, Huber K, et al. | Health Affairs Scholar
Addressing health-related social needs was one of 6 Medicaid improvement priorities identified by interviewed community members.
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