In May 2017, the US Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) model, a 5-year initiative to bridge a critical gap between clinical care and community services in the current delivery system. The initiative tested whether systematically identifying and addressing the health-related social needs (HRSNs) of Medicare and Medicaid beneficiaries through screening, referral, and community navigation would reduce health care utilization and expenditures. health. As one of the first 32 winners, the Parkland Center for Clinical Innovation (PCCI) served as alignment track organization of the bridge. PCCI has partnered with 17 clinical sites, representing five Dallas health care systems and more than 100 local community organizations (CBOs), to establish the Dallas Accountable Health Community (DAHC). Using an HRSN screening tool developed by CMS, PCCI and its partners selected 12,548 unique recipients from Dallas County who met the model’s eligibility criteria. PCCI and partner community health workers provided 9,161 unique individuals with active navigation services consisting of referrals to aligned CBOs, accompanied by monthly follow-up calls for up to 12 months or until HRSNs documented are successfully processed. Over the course of the initiative’s five years, PCCI identified more than 19,000 distinct needs, with 61% of people having two or more concurrent needs. Through the referral process, community organizations provided a host of support services, including more than 200,000 pounds of food and $540,000 in utilities and rental assistance. The results show that people actively browsing experienced a greater decrease in ER visits per person than those in a comparable control cohort, with the browsing cohort having a statistically significant reduction in average ER use, both during active navigation and within 12 months after navigation. The navigated cohort also demonstrated a greater likelihood of seeking – and retaining – outpatient visits compared to the control cohort. Although hospitalizations were reduced in both cohorts, the differences between the cohorts were not statistically significant. Excluding response costs provided by CBO and using model year 4 data (May 2020 through April 2021), DAHC demonstrated a positive ROI of 1.3:1 with gross savings exceeding $1.25 million. The impact analysis considered the dynamic and multi-dimensional impact of Covid-19 through an innovative control group matching algorithm. This study demonstrated the nature and scope of HRSNs among a high-risk vulnerable population in Dallas County, a positive impact on health care outcomes, and a more moderate impact on expenditures using regular active navigation of engaged beneficiaries. Importantly, DAHC has shown that combining clinical care with appropriate social services to reach HRSNs – at the right time and by the right staff – results in lower utilization and lower healthcare costs. These two factors alone argue for expanding the initiative to other at-risk populations while establishing the sustainability of the initiative.