- As part of the Accountable Health Communities Model, CMS recently selected 32 organizations to participate in two of the three program tracks that aim to lower healthcare costs and utilization by fostering clinical and community service provider collaborations.
The 12 bridge organizations chosen for the model’s Assistance Track intend to deliver person-centered community navigation services to help high-risk Medicare and Medicaid beneficiaries with accessing necessary care.
For the 20 Alignment Track bridge organizations, CMS expects participants to provide community navigation services as well as promote community-level collaboration to ensure that beneficiaries can access needed health-related services and supports.
The organizations represent urban and rural communities from 193 counties in 23 states, CMS added.
“We know that innovation at the state and community level is essential to improve health outcomes and lower costs,” stated Patrick Conway, MD, CMS Deputy Administrator for Innovation and Quality. “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.”
CMS established the three-track Accountable Health Communities Model last year. Under the population health management program, clinical and community actors pinpoint and address health-related social needs of Medicare and Medicaid beneficiaries, such as housing instability, food insecurity, utility needs, interpersonal violence, and transportation.
Through improved screening, referral, and community navigation services, CMS plans to test if addressing health-related social needs will reduce healthcare costs and utilization.
The five-year model is divided into three components: the Awareness, Assistance, and Alignment tracks. With each track, the federal agency intends to boost beneficiary awareness of available community services, assist high-risk beneficiaries with accessing the services, and aligning community and clinical partners to ensure appropriate community services are available.
Each track will contain bridge organizations that function as “hubs” in their communities. CMS expects each bridge organization to develop and coordinate groups that will:
• Identify and collaborate with clinical delivery sites, such as physician practices, behavioral health providers, clinics, and hospitals
• Perform regular health-related social needs screenings for all beneficiaries and make appropriate referrals to community services that can address the social needs
• Connect beneficiaries to proper community service providers through community service navigation
The Alignment track bridge organizations must also align model partners to maximize their community’s capacity to address health-related social needs.
As part of the recent announcement, CMS gave examples of how selected Assistance and Alignment bridge organizations plan to lower healthcare costs and utilization.
In the Assistance track, the Indianapolis-based Community Health Network Foundation will collaborate with the Eastside Redevelopment Committee, a healthcare association that represents 50 business and community-based organizations.
The partnered organizations will serve East Indianapolis residents, a community where 40 percent of the population received Medicaid services in 2015 and emergency department utilization rates were above the national average.
The Oregon Health & Science University will serve as an Alignment track bridge organization and target over 300,000 Medicare and Medicaid beneficiaries across nine rural counties. The university will partner with over 50 clinical sites, community service providers, and local health departments.
All model activities will run through the Oregon Rural Practice-Based Research Network, a statewide group of primary care providers, community partners, and academics who study and address rural healthcare and care disparities.
Bridge organizations will receive CMS funding to develop and support infrastructure and staffing models. However, the reimbursement should not be used to establish community services.
The Assistance and Alignment track bridge organizations will launch the Accountable Health Communities Model in their regions on May 1.
CMS anticipates announcing participants for the Awareness Track by summer 2017.