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roadmap

Built on a foundation of years of existing research and learning

Included below are citations for several of the most influential tools, resources and recommendations drawn on by our Steering Committee and Contributing Partners as they developed the Essential Needs Roadmap.


ID & Screening


Navigation & Resource Connection

  • The domain descriptions under launch, refine and scale/integrate are the result of a consensus position from design contributors.
  • Definitions for general and tailored resource referrals can be found on pages 8 and 19 of the CMS Funding Opportunity: AHC application document, released on 5 January 2016.
  • See also the AHC Implementation Plan for more on the drivers associated with the model’s success, which articulates the need for an established referral process.

Social Health Needs Team & Workflow

  • The domain descriptions under launch, refine, and scale/integrate are the result of a consensus position from design contributors.
  • For an example of how to build care-based teams see the Safety Net Medical Home Initiative’s Implementation Guide: Continuous and team-based healing relationships, improving patient care through teams.
  • Additional resources on different types of social health needs teams and interventions include Kangovi S, Mitra N, Grande D, et al. Patient-centered community health worker intervention to improve post-hospital outcomes: a randomized clinical trial. JAMA Intern Med 2014;174:535–43; Peek ME, Ferguson M, Bergeron N, et al. Integrated community-healthcare diabetes interventions to reduce disparities. Curr Diab Rep 2014;14:467; and Philis-Tsimikas A, Walker C, Rivard L, et al. Improvement in diabetes care of underinsured patients enrolled in project dulce: a community-based, culturally appropriate, nurse case management and peer education diabetes care model. Diabetes Care 2004;27:110–15.
  • For cases studies on Community Care Team initiatives, go to the Center for Health Care Strategies blog.

Community Partnerships

  • The domain descriptions under launch, refine, and scale/integrate are the result of a consensus position from design contributors.
  • The majority of content for these pages were developed based on Health Leads’ extensive experience developing and refining referral resource databases.
  • The need for consistent and accurate referrals is reflected in CMS AHC model. The key intervention elements of each track all outline the need for healthcare organizations to have an inventory “of local community services responsive to community needs assessment” (pg 8) – CMS Funding Opportunity: AHC application document, released on 5 January 2016.
  • One example of an intervention aimed at reducing health disparities through community partnership is the South Side Diabetes Initiative in Chicago. For an assessment of its outcomes see Peek ME, Wilkes AE, Roberson TS, et al. Early lessons from an initiative on Chicago’s South Side to reduce disparities in diabetes care and outcomes. Health Aff (Millwood) 2012;31:177–86.
  • For additional thoughts on ways to bolster community partnerships check out Democracy Collaborative’s project, Hospitals Aligned for Healthy Communities.

Data & Evaluation


Leadership & Change Management

  • The domain descriptions under launch, refine, and scale/integrate are the result of a consensus position from design contributors.
  • The questions developed on pages 26 to 28 take from basic change management principles and framework such as Lewin’s Change Management Model  and Prochaska’s Understanding Stages of Change.
  • For an additional example of a change management theory, see the Transtheoretical Model.
  • The Safety Net Medical Home Initiative has developed the a set of strategies for engaging leadership during times of change. While these strategies are specific to the Patient-Centered Medical Home (PCMH) Model of Care, the initiative covers principles that can be applied generally to any change process.