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CMS Looks to Integrate Clinical and Community Care

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The Accountable Health Communities (AHC) model, announced by the Centers for Medicare & Medicaid Services (CMS) in January 2016, is a pilot program that aims to link clinical care with community resources. With this model, CMS aims to improve overall care by steering Medicare and Medicaid beneficiaries to social services available in their communities.

Today we talk with Senior Manager Emma Mandell Gray, who describes the AHC program and the three approaches organizations can take to participate.

What is CMS trying to accomplish with the AHC program?

The purpose of the program is to bridge the gap between clinical care and health-related community services. Providers and health organizations have typically focused on addressing patients’ clinical needs and the conditions they present with. But beyond the walls of the physician office or hospital, most providers aren’t looking at socioeconomic and other factors that affect the way a person lives his or her life. As it concerns the Medicaid population, you have a lot of patients with low or no income. Among the Medicare population, you have elderly, sicker patients, many of whom may have trouble getting around. These are particularly vulnerable populations, and there’s increasing evidence that clinical care outcomes and costs can be improved by accounting for these issues.

How is CMS encouraging provider organizations to help these populations?

Organizations can apply to participate in one of three tracks – Awareness, Assistance, and Alignment – and will receive incentives ranging from $1 million to $4.5 million, depending on the track selected. Regardless of which track they choose, participating AHC clinical delivery sites will be required to screen all Medicare and Medicaid beneficiaries to identify their unmet socioeconomic needs. CMS will develop and deploy a universal comprehensive screening assessment tool, which will serve as the foundation for the AHC model.

Track 1 is called “Awareness.” What does this entail?

On the care delivery side, this is an opportunity for providers to discover whether any of these issues are affecting their patients. Then it’s making patients aware of resources that are available to them and the fact that they actually might need them. For example, patients are not always thinking “I can’t get my medication because I don’t have transportation”; they’re just thinking, “I can’t get my medication.” So the foremost priority of Track 1 is educating patients on how factors such as transportation could be affecting their healthcare and making them aware of services that are available to them. As part of their assessment, providers will give patients material to let them know what relevant resources exist in the community.

But they aren’t responsible for actually linking the patient to a given service.

Track 1 only requires awareness and a community referral summary, but organizations may decide to use the summary to provide linkages to services as needed. That’s the essence of Track 2, which encompasses all of the activities from Track 1 but extends to providing a referral to the community resource and then doing intense follow-up – making sure that the patients actually receive the services, helping them if they need any type of authorization or additional information, and so on.

Does the provider organization need to have a relationship with these community resources?

That’s at the heart of Track 3, which is Alignment. Organizations participating in this track will still be responsible for conducting the screening, providing the referral summary, and putting patients in touch with community resources. But Track 3 involves creating partnerships with those entities – social services, health departments, and other resources. The organization would work proactively with these partners to identify gaps and address them.

Take transportation, again, as an example. There may be a need for taxi cab rides, or for affordable busing. The organization will work with a taxi company to understand services offered, schedules, accessibility for handicapped individuals, and so forth.

Organizations can apply to participate in any of the three tracks, but they will only be selected for one. Do you see certain tracks as being appealing to particular types of healthcare organizations?

Organizations should pursue whichever track makes the most sense for them, and CMS offers a readiness assessment to help them determine which track is best. That being said, some organizations are further along than others in terms of assessing socioeconomic factors as part of their care model. Healthcare organizations that are unsure about what sorts of issues might be affecting their patients, or unaware of what resources are available in their community, should consider Track 1. It would be an education opportunity for them as well as for their patients. Track 3 is probably best for organizations that are already aware of their patients’ social needs, know what community services are available, and are ready to start building those partnerships. In any case, it’s best to take a phased approach because organizations first need to understand their patient population and the resources in the community.

Emma Mandell Gray is a Senior Manager with ECG and has written extensively about care model transformation. Her recent blog post about the opportunities that the AHC model presents for AMCs and teaching hospitals can be found here.