The Social Question

The Accountable Health Communities Training Team at UTHealth School of Public Health is working to integrate healthcare and public health implementation teams to address social needs of patients.


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By Gayla Ferguson, MPH and Linda Highfield, PhD
UTHealth School of Public Health 


At the heart of the Houston-based Accountable Health Communities (AHC) project is a stark fact: the $3.5 trillion the United States spends annually on cutting edge medical interventions is only responsible for about 10% of a person’s health outcomes. In contrast, the under-resourced and often overlooked upstream drivers of health, such as food access, housing, transportation, and personal finance, are responsible for up to 40%.

That 40% is the target of the AHC project, which is funded by the Centers for Medicare and Medicaid Services (CMS), and is being conducted at UTHealth School of Public Health in partnership with Memorial Hermann Health System, Harris Health System and UT Physicians. In particular, the project is based on the idea that addressing a patient’s social needs during routine health care visits, emergency department visits, or labor and delivery stays can reduce healthcare utilization and cost and improve health outcomes.

At each program site, Medicare and Medicaid patients are screened for social needs in five domains: housing instability, food insecurity, difficulty paying bills, transportation and personal safety. They’re then provided a referral to community resources to address identified needs. A subset of patients receives additional assistance, or “navigation,” in order to facilitate their connection to community agencies and services. Navigation can include assisting with requirements like paperwork and counseling them through any barriers and concerns they may have.

In order to implement these programs effectively, AHC assigns an implementation team to each site. The team works with staff and patients to develop a comprehensive, written plan for program implementation, and train staff on each phase of the process. This training includes more classroom-like instruction as well as hands-on practice screening, referring, providing navigation to actual patients. 

When the healthcare staff is ready, the AHC training team trades roles and shadows the staff as they implement the program. Over time, the staff become so versed in the protocols that they are able to not only train new staff themselves and continually revise and refine the overall structure. 

The AHC training team’s approach has led to a greater than 90% opt-in rate for patient navigation, which is one of the highest success rates in the AHC model nationally.  To date, the AHC team has trained 26 staff members. The AHC implementation teams have screened and referred 4,400 patients for social needs and navigated 1,200 patients to community resources in just over six months of implementation.