Professional Standards

Centers for Medicare & Medicaid Services

• CMS manages the federal funding

• Value-Based Care *need to advocate for smaller organizations so they can access timely staff funding*

Accountable Health Communities Model

• Health-Related Social Needs (HRSNs)

• AHC Model reduced total health care expenditures and improved quality of care

• https://www.cms.gov/priorities/innovation/innovation-models/ahcm

Upstream Factors/Management

• Prevention rather than treatment
• Environment and Living Circumstance
• Health Organization Activities

“Problem: Delayed detection of chronic conditions, financial incentives that encourage unnecessary procedures, and the lack of care coordination among specialists and primary care providers all contribute to poor health outcomes for people who are at risk for or living with chronic disease. These include delayed diagnosis and poor disease management.

Solution: ASM will promote preventive care and more effective upstream chronic disease management by rewarding specialists for improving patient health outcomes and coordination with primary care providers.” Quoted from CMS 10/31/2025

Additional Examples of CMS Priorities

• https://www.cms.gov/priorities/innovation/innovation-models/transforming-maternal-health-tmah-model

• https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

CHWs use Versions of these Assessment Forms

General Assessment Form

Social Determinants of Health 5Q Assessment

Member Benefit Assessment Form

Case Note Example

Ace Assessment Tool