Alliance Model Awareness Assistance Alignment

The Alliance Model

The Alliance is based on the three-pronged CMS Accountable Health Communities Model of awareness, assistance, and alignment. The work is intended to inform best practices and provide a model for scaling to other geographies and health systems.



Little boy playing in a classroom

In one community, a Parents as Teachers Program is now receiving direct referrals from a pediatric office who is screening for social determinants of health. This two-way link between a physician’s office and social service provider creates more immediacy in children getting connected to developmental services, which is a vital piece to kindergarten readiness.

Both school readiness and developmental delays show a direct correlation to social determinants of health. Likewise, it has provided the medical office more resources to serve the whole family and another layer of expert intervention for children with barriers that reach deeper than medical treatment.

Man sitting in dentist chair at dentist office.

A patient at the Federally Qualified Health Center (FQHC) was screened and referred to a Community Health Worker (CHW) for assistance with clothing and food insecurity. During the screening assessment, it was noted that this participant also had long standing dental needs, which he had avoided addressing due to severe anxiety about going to the dentist.

The CHW shared the barrier with the group, and as a result the FQHC arranged for a behavioral health provider and CHW to accompany this participant to their dental visit for support. The participant had a positive experience and established a trusting relationship with the dentist which resulted in an appointment for follow up care.

Alignment of services

As the screening workflows were developed and implemented, the group collectively decided the next step of improvement was focusing on the hardest to reach members which would be measured by CHWs completing a full assessment with participants.

Each organization then identified and adopted specific goals that would improve their workflow process for engagement. For example, one organization focused on warm hand offs to CHWs which involved notifying the CHWs of high-risk members upcoming office visits.