Can social workers’ knowledge of health-related issues be useful in achieving better health outcomes? The Department of Health and Human Services (HHS) thinks so, and it will provide up to $157 million in funding to 44 bridge organizations over a five-year period to determine how effective these organizations are in connecting consumers of clinical services with social service agencies addressing issues related to clients’ wellbeing. Funding for the Accountable Health Communities Model will be provided through the Affordable Care Act to assess the efficacy of social work interventions addressing social determinants of health and well as clinical practice.

The federal government’s interest in the social determinants of health was underscored at the 2013 White House briefing hosted by the Council on Social Work Education (CSWE) entitled: Addressing the Social Determinants of Health in a New Era: The Role of Social Work Education. The focus of the briefing was the need to prepare the next generation of social workers for healthcare reform spurred by the Affordable Care Act’s emphasis on integrative healthcare models.

One panel on New Expectations for Health Care focused on what the new era of health care will look like with respect to integrated care, interprofessional health care teams, and consideration of social determinants of health. Panelists emphasized the importance of linkages and connectors between the community and health care providers and the value of social workers in making those connections.

The Center for Medicare and Medicaid Services (CMS) will implement and test a three-track model of service delivery. The first track (Track 1 Awareness) will focus on a participating organization working to increase awareness among community residents through referrals and information dissemination. Track 2 (Assistance) will rely on navigators to actively assist high-risk resident in connecting with available resources in the community.

The third track (Track 3 Alignment) will involve organizations working to align community partners to ensure services are beneficial and accessible to community residents. Funds are not allowed to be spent of the services required by consumers. CMS will award 44 cooperative agreements ranging from $1 million for a Track 1 initiative to $3.5 million for a Track 3 initiative.

All participating organizations are expected to identify and partner with clinical delivery sites (CDS). They must conduct comprehensive social needs screenings, make referrals for eligible Medicare and Medicaid beneficiaries, and connect community residents with specific unmet health-related social needs to community service providers that might be able to address those needs.

Track 3 organizations must also align effective partners to maximize community capacity to address health-related social needs in the core areas of housing instability and quality, food insecurity, utilities, interpersonal violence and transportation shortages. Applicants will partner with state Medicaid agencies, clinical delivery sites, and community service providers and are responsible for coordinating community efforts to improve linkage between clinical care and community services.

Eligible applicants include community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations and for-profit and not-for-profit local and national entities from all 50 states, U.S. Territories, and the District of Columbia. CMS will award renewable one-year cooperative agreements to successful applicants.

Organizations may apply for funding in one or two tracks, but will be selected to participate in a single track only that will run for a five-year period. Detailed information about the various track can be obtained from the Funding Opportunity Announcement (FOA). Interested organizations have until February 8 to submit and non-binding Letter of Intent (LOI). CMS will be accepting applications until March 31, 2016.

Questions about the model and applications can be submitted toAccountableHealthCommunities@cms.hhs.gov. Interested parties can register for a January 27 webinar on the application process.