CMS’ Accountable Health Communities (AHC) and Comprehensive Primary Care Plus (CPC+) pilots represent the first government-funded integration of social needs interventions into healthcare. Combined, these pilots will drive the number of patients systematically screened for social needs from tens of thousands per year to ~15 million.

With these pilots, the world’s largest purchaser of healthcare has put a stake in the ground that better healthcare can’t be achieved without addressing the social determinants of health.

To say we are excited about these opportunities is an understatement. But our biggest fear? Any provider organization struggling to build an effective intervention, when we have the proven solutions, clinical and community expertise, and 20 years of experience to help.

Whether you are participating in an AHC or CPC+ pilot or inspired by them, we have the tools and resources to support you every step of the way:

  • Health Leads Prepare Workshop: This six-week session leads participants through the basics of social needs interventions and ends with a tangible Action Plan.
  • Health Leads Assessment & Design Services: Our consultants will work closely with you to build a customized, detailed blueprint for your social needs intervention.
  • Health Leads Reach: Our cloud-based electronic health record for social needs satisfies all AHC and CPC+ requirements, including case management and local resource directory, and easily integrates with existing systems.

FREE Resources:

    • Health Leads AHC Workshop: Email us to download the recording of our three-hour guidance on the necessary steps to meeting AHC requirements. And sign up for our newsletter to hear about our next AHC Workshop for grantees, coming soon!
    • Social Needs Screening Toolkit: Screening for unmet social needs is a key measure in both CMS pilots. Ensure screening effectiveness with our recommended tool and questions library.
    • CMS Social Needs Screening Tool: Learn the best practices for standardized screening in this free guide and streamlined patient-friendly screening template for hospitals and clinics participating in AHC pilots.
    • ACO Primer: As we move toward rewarding the integration of health-related social needs into clinical care, this primer reveals how to implement and sustain high-impact, cost-effective social needs programs in a value-based care world.


Do you have specific questions about these pilot programs and how we can help? Please email

Health Affairs

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