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What We Do

Accountable Health Communities Model

The World Health Organization refers to social determinants of health to acknowledge the conditions in which people are born, grow up, work, live and age as well as the wider set of forces and systems shaping conditions of daily life. The five key areas of social determinants are: neighborhood and built environment; health and health care; social and community context; economic stability; and education.

The Northwest Colorado Community Health Partnership is the lead agency for the Accountable Health Communities Model in the Yampa Valley. By examining how health-related social needs of Medicare and Medicaid recipients impact the overall health care system, the model addresses the identified social determinant gap between clinical care and community services.

The model consists of three major components: screening for social determinants at primary care visits, emergency room visits, and other visits; resource connections (enhanced 2-1-1 referrals); and community navigation.