In 2017, the Innovation Center launched the AHC Model to assess whether identifying and addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSNs) would reduce health care use and costs. The Innovation Center funded entities called bridge organizations to convene a coalition of clinical delivery sites (CDSs) and community service providers (CSPs) to implement the AHC Model in communities across the country. Under the AHC Model, Medicare and Medicaid beneficiaries were screened by participating entities for five core HRSNs, and up to 8 supplemental HRSNs.
The AHC Research Identifiable File (RIF) contains beneficiary-level screening and navigation information about individuals participating in the AHC model. Participants included Medicare and Medicaid enrollees, 94% of whom can be linked to other CMS research files. The remaining 6% cannot be linked to Medicaid or Medicaid claims, since their Medicare and/or Medicaid ID was either missing or incomplete.
The file contains data for the entire AHC Model performance period, which began on May 1, 2017 and concluded on April 30, 2023. Screenings were conducted between May 1, 2018, and January 31, 2023, and navigation services were provided to those with at least one health-related social need (HRSN) and two or more emergency department (ED) visits between May 3, 2018, and April 30, 2023.
The file includes one record per beneficiary screening, with some beneficiaries having more than one screening. For each beneficiary, screening outcomes across domains (e.g. food, housing, safety, transportation, utilities) are reported. Some beneficiaries also have supplemental indicators related to disabilities, education, employment, family and community support, mental health, physical activity, and substance use. For screened items where a need is identified, the file contains information about services offered and their outcomes.
What does this file include? (variable highlights)
- Person level identifiers (i.e., BENE_ID, MSIS_ID) that researchers can use to link to other CMS research files
- Sociodemographic variables (e.g., date of birth, race and ethnicity, education, income)
- HRSN screening results (e.g., HRSNs reported, number of ED visits in the 12 months prior to screening)
- Navigation case information for those who were eligible and opted in to receive navigation (e.g., navigation case start and end dates)
- Contacts between navigator and beneficiary who received navigation services (e.g., total number of successful contacts during the navigation period)
- Navigation outcomes (e.g., beneficiary reported connection with a community service provider, beneficiary had their HRSN(s) resolved)
Special Considerations
Most beneficiaries (94%) in the file have been linked to an identifier (BENE_ID and/or MSIS_ID) that researchers can use to link to other CMS research files. For more information on how to use the data, please refer to the Accountable Health Communities (AHC) Model Data File User Guide.
