ANCHOR (Addressing the Needs of the Community through Holistic, Organizational Relationships)

In 2017, the Division of Community and Population Health received a five-year grant from the Center for Medicare and Medicaid Innovation (CMMI) Accountable Health Communities (AHC) program to systematically identify the health-related social needs of Northern Manhattan/South Bronx Medicare and Medicaid beneficiaries and address their identi§ed needs through referrals to local community-based social service organizations. The Division is leveraging this grant’s resources to standardize and expand its existing Ambulatory Care Network pre-visit screening efforts. By systematically screening for healthrelated social needs and clinical risk factors, ANCHOR seeks to identify the most vulnerable patients and improve their access to preventative services through a combination of social and clinical interventions in the community.