by Trudie Bruno, Customer Success Manager

Camden Coalition and Aunt Bertha tackle AHC requirements together.

Camden Coalition, founded by Dr. Jeffrey Brenner in 2002, is an organization of hospitals, providers, and advocates that collaborate to deliver healthcare to the most vulnerable people in their community. They are one of 32 organizations selected to participate in the Accountable Health Communities (AHC) initiative through the Centers for Medicare and Medicaid Services (CMS). This initiative aims to bridge the critical gap between clinical and community service providers by addressing health-related social care needs, aligning well with the missions of both Camden Coalition and Aunt Bertha. In 2018, Aunt Bertha and Camden Coalition collaborated to build assessment workflows to enable Camden’s success in the AHC Model.

Aunt Bertha has features built to meet AHC requirements, including integrated screening, navigation, goal tracking and reporting. Let’s dive into more detail on how some of these tools help meet AHC requirements.

Needs Assessments

1. AHC-eligible beneficiaries are able to complete a web-based assessment to identify social care risks and needs.

2. Camden staff help eligible AHC beneficiaries complete or administer the screening.

3. Needs identified through the assessment are then used to recommend social care resources as well as an action plan.

4. Results from the assessment can be reviewed at any time and goals can be updated and tracked over time.


1. Referrals are tracked through the Aunt Bertha platform and allow updates to be made in real time.

2. The Seeker, staff, or the Community Based Organization can “close the loop” to indicate if the community member was able to get help.


1. Camden Coalition and Aunt Bertha collaborated closely on designing the workflows to ensure a smooth process for both staff and community members.

2. The navigation tools represent a central location from which individual member profiles can be reviewed and updated.

3. Staff manage goals, needs, referrals, assessment results, contact information, and more.


1. Aunt Bertha offers a detailed reporting suite and has the capability to create CMS-required reports, which was essential for the Camden Coalition AHC project.

2. AHC specifications require a weekly data submission and Aunt Bertha regularly runs and maintains these reports, which are then submitted to CMS by Camden Coalition to meet the demonstration project goals.

3. Since the Camden project launched in 2018, over 3,700 assessments have been submitted. Recently, the frequency of completed submissions has grown to over 1,000 completed submissions each month.

4. Camden Coalition is an impactful example of an innovative team using our tools to demonstrate new ways to support community health and wellness. Through thoughtful collaboration, our teams developed tools, workflows, and a community-facing experience that keeps the Seeker at the center.

The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.