CMS Chooses 32 Accountable Health Communities to Bridge Gaps in Social Needs

CMS has announced which community organizations will participate in the Accountable Health Communities (AHC) model established by the Center for Medicare and Medicaid Innovation. The model aims to address the complex social needs impacting beneficiaries’ health by strengthening a support network of clinical and community services.

The AHC model comprises 3 tracks, but the announcement from CMS specified the 32 organizations that would take part in the Assistance Track and the Alignment Track. Further details on the participants within the Awareness track are expected this summer. For all 3 groups, the goals of the initiative are to reduce health service utilization by improving wellness among Medicare and Medicaid beneficiaries with complex needs, but the different tracks will allow for experimentation with several potential solutions.

For instance, the 12 organizations in the AHC Assistance Track will work to link high-risk beneficiaries with navigation services within the community to help them access the care they need. CMS’ announcement highlighted the Community Health Network Foundation in this track, which in conjunction with the Eastside Redevelopment Committee will provide support and navigation assistance for beneficiaries in East Indianapolis.

The Alignment Track, on the other hand, will incorporated navigation services but will also “encourage community-level partner alignment to ensure that needed services and supports are available and responsive to beneficiaries’ needs.” The Oregon Health & Science University, one of 20 chosen bridge organizations, will target rural healthcare costs and utilization in a partnership with local community organizations and researchers, according to the announcement.

Another Alignment Track organization is the Camden Coalition of Healthcare Providers, which uses hotspotting to identify high-needs patients in the Camden, New Jersey, community and provide interventions that empower patients to improve their domains of care. It has also launched the National Center for Complex Health and Social Needs, which brings experts in the field together to collaborate on ways to improve care for costly patients with significant social needs.

The 32 organizations selected by CMS include county governments, universities, hospitals, nonprofit groups, and health departments of various sizes that operate in urban and rural locations and serve a diverse array of beneficiaries. They will all participate in the model by functioning as a “hub” connecting members of their community with not just clinical services, but also initiatives to reduce the health-related social needs that contribute to health disparities, like housing instability, food scarcity, transportation issues, and violence.

Organizations were invited to apply to the model in January 2016, and the accepted groups will begin their work on May 1 and continue for a 5-year performance period. The organizations will receive funds to help with infrastructure and staff employment costs, but the grants will not pay directly or indirectly for community services like providing housing or food, according to CMS.

Officials are optimistic that the model will provide a cost-effective approach to mitigating the community-level disparities that affect health.

“We know that innovation at the state and community level is essential to improve health outcomes and lower costs. In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country,” said Patrick Conway, MD, deputy administrator for Innovation & Quality at CMS, in the announcement. “As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries, and their families and caregivers.”