CMS and Accountable Health Communities Model: Connecting  Clinical Care with Community Resources

For better than never is late.

Geoffrey Chaucer (1343-1440), The Canterybury Tales

This the latest CMS initiative.

“The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery.”

The CMS-AHC, as it is called in government circles. will focus on the following:

The Model aims to identify and address beneficiaries on these “unmet”’ health-related social needs.

·         Housing instability and quality

·         Food insecurity

·         Utility needs; 

·         Interpersonal violence

·         Transportation needs. 

In other words,  if patients  have too little food,  don’t have an adequate place to live, can’t heat  or turn on the electricity where they live, are being physically abused,  have no means of medical transportation,  CMS will help a way to help patients cope with their problems.

CMS will issue grants that encourage physician community collaboration  testing the impact  of  Accountable Health Communities interventions on total health care costs and inpatient and outpatient health care utilization, as well as health and quality of care for Medicare and Medicaid beneficiaries.

CMS will test whether community referral, community service navigation, or community service alignment impacts total cost of care, emergency department visits, inpatient hospital admissions, and quality of care for high-risk Medicare and Medicaid beneficiaries.

Over a 5 year period, CMS has budgeted $180 million  to implement and test a three-track model based on promising service delivery approaches. Each track features interventions of varying intensity that link beneficiaries with community services:

Track 1 Awareness – Increase beneficiary awareness of available community services through information dissemination and referral

Track 2 Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services

Track 3 Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries.

That’s the CMS-AHC model in a nutshell.

Late to the Party

CMS is late to the “unmet needs” party.    Physicians have known for a long time they cannot meet   patients’  health needs  once they leave the office or the hospital.  Others recognize this need as well.

·         In 2006,  Satcher and Pamies pointed out  in thier book  Multicultural Medicine and Heatlh Differences  that a nation’s health system accounts for only 15% of a nation’s health status, life style makes for 30% and other factors – poverty, inferior education, income differences, and lack of social cohesion make up the other 55%. Therefore, any reform of our system is unlikely to increase the nation’s overall health status. In other words, a nation’s culture and its life style habits determines its health.

 

·         In 1996 Rebecca Onie, then a Harvard sophomore and now CEO of Health Leads, co-founded  Project Health (since renamed Health Leads,  which establishes “health desks” in  multiple hospitals and clinics across the U.S,  Health Leads recruits college volunteers to man these desks,  which respond to  doctor “prescriptions” asking the volunteers to connect patients to community agencies.  The agencies connect poor families to sources of food supply,  to social workers,  to home care nurses, to housing agencies,  to social workers, and to medical transportation companies to help families in need.   Health Leads in now in more than a dozen American cities  has raised or received millions of dollars of support from the Skoll Foundation , the Robett Wood Johnson Foundation, New Profit (a venture philanthropy firm), and the Physicians Fobdatuib,  In 2015,  Health Leads have more than 900 volunteers that help find community support for over 13,000 need families..

CMS calls its Accountable Health Care Model,  an “initiative.” The “initiative” and recognition  for filling the gap between clinical care and community services first came from outside government.   Only the government, however,  has the resources and reach to make filling this gap a national effort.