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Track 2 - Assistance: Greater New Haven AHC Project: Tailored Community Referrals and Intensive Navigation for Randomized qualified Beneficiaries w/2 or more ED visits in Prior Yr and 1 or more HRSNs

Award Number: 1P1CMS331558
ORGANIZATION: HEALTH CARE FINANCING ADMINISTRATION, OFFICE OF ACQUISITION AND GRANTS
OPDIV: CMS
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: DEMONSTRATION

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Yale-New Haven Hospital, Inc. (YNHH), Fair Haven Community Health Center (FHCHC) (one of two local federally qualified health centers) and Cornell Scott-Hill Health Center (CS-HHC) (the other local FQHC) formed the New Haven Primary Care Consortium (NHPCC) over the last 12 months to better address primary care for underserved populations in Greater New Haven (GNH), defined as New Haven, East Haven, West Haven and Hamden, CT. GNH is racially and ethnically diverse: 26.1% of the population are black or African Americans; 58.9% are white, non-Hispanics; 19.5% are Hispanics. Fifteen percent of this population lives in or near poverty with 58% of children living in low-income households. As part of New Haven County, the GNH area ranks worst in health outcomes among the 8 counties in the state and ranks second to last in health factors, including Quality of Life, Health Behaviors and Social & Economic Factors. NHPCC is applying to CMS to execute a Track 2 Accountable Health Communities (AHC) program to supplement their individual organizational efforts and bring a consistent approach to screening and referring eligible beneficiaries with the most severe health-related social needs (HRSNs) to the limited existing community resources within GNH. The two primary program aims address basic cost and process outcomes for GNH AHC: (1) decreasing overall health care costs for Medicare and Medicaid beneficiaries in GNH by 2% by December 31, 2021, and (2) improving their health utilization by December 31, 2021. Secondary aims further define how GHN AHC will know it has met its primary aims and are aligned with metrics proposed for the CT Healthcare Innovation Plan and the GNH Health Improvement Plan to facilitate additional stakeholder engagement and progress reporting. We expect to achieve lower overall health costs by reducing avoidable ED utilization by 5% and decreasing 30-day readmissions by 5%. We will demonstrate improved health care utilization by (1) increasing the percent of low-income beneficiaries identifying a primary care provider by 5%, (2) increasing the percent of well-child visits in the first 15 months of life by 2% and (3) increasing the percent of beneficiaries self-reporting very good or excellent health by 5%. Of the estimated 276,487 individuals living in GNH, over 40%, 116,689, are estimated by federal and state censuses to be Medicare or Medicaid beneficiaries. Over 92,000 of these (79%) were touched by one or more NHPCC entities in FY 2015. A majority of them reside in or live adjacent to a HRSA-designated MUA or HPSA. Over 22,000 of the 92,000 had 2 or more ED visits in FY 2015. To care for these individuals, NHPCC has access to over 4,300 clinicians, 4,110+ at YNHH, 65+ at FHCHC and 180+ at CS-HHC. Given the variety of avenues through which beneficiaries will engage with GNH AHC (ambulatory, ED, inpatient), any of the 4,300 clinicians may participate in the program along with numerous administrative resources as well. GNH AHC is seeking $2,497,759 over 5 years to fund the project. NHPCC organizations have agreed to absorb screening and referral activities into their existing standard of care. The vast majority of project funds will support the two FOA-required full-time positions for program manager and screening and referral specialist along with four full-time navigators to deliver intense navigation services to beneficiaries randomized into the AHC intervention group. The budget also contains 10.2% in funds for IT integration to enhance existing IT systems to ensure GNH AHC has the capacity to (a) identify beneficiaries at each point of entry and gather, use and analyze the data needed to execute, monitor and manage the project and (b) supply the data that CMS and its independent evaluation contractor need to oversee and evaluate program progress.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2023 ( Subtotal = -$2,993 )
2023	2021	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	03	5	8/31/2023	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	-$2,993
2023	2020	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	03	5	8/31/2023	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2023	2019	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	03	5	8/31/2023	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2023	2018	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	03	5	8/31/2023	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2023	2017	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	03	5	8/31/2023	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = -$2,993

Issue Date FY: 2022 ( Subtotal = $0 )
2022	2021	YALE NEW HAVEN HOSPITAL, INC.	20 YORK ST	NEW HAVEN	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	02	5	4/29/2022	EXTENSION WITH OR WITHOUT FUNDS	$0
														Subtotal = $0

Issue Date FY: 2021 ( Subtotal = $410,002 )
2021	2021	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	01	5	9/23/2021	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2021	2021	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	00	5	4/29/2021	NON-COMPETING CONTINUATION	$410,002
2021	2020	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	02	4	12/22/2020	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $410,002

Issue Date FY: 2020 ( Subtotal = $545,636 )
2020	2020	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	01	4	8/31/2020	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2020	2020	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	00	4	4/30/2020	NON-COMPETING CONTINUATION	$545,636
2020	2019	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	02	3	11/26/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $545,636

Issue Date FY: 2019 ( Subtotal = $534,121 )
2019	2019	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	01	3	9/17/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2019	2019	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	00	3	4/30/2019	NON-COMPETING CONTINUATION	$534,121
2019	2018	Yale New Haven Hospital, Inc.	20 York St	New Haven	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	02	2	3/27/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $534,121

Issue Date FY: 2018 ( Subtotal = $540,831 )
2018	2018	YALE NEW HAVEN HOSPITAL, INC.	20 YORK ST	NEW HAVEN	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	01	2	7/27/2018	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2018	2018	YALE NEW HAVEN HOSPITAL, INC.	20 YORK ST	NEW HAVEN	CT	06511	SOUTH CENTRAL CT	USA	Accountable Health Communities	00	2	4/30/2018	NON-COMPETING CONTINUATION	$540,831
2018	2017	YALE-NEW HAVEN HOSPITAL, INC.	20 YORK ST	NEW HAVEN	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	02	1	11/13/2017	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $540,831

Issue Date FY: 2017 ( Subtotal = $468,380 )
2017	2017	YALE-NEW HAVEN HOSPITAL, INC.	20 YORK ST	NEW HAVEN	CT	06510	SOUTH CENTRAL CT	USA	Accountable Health Communities	00	1	4/4/2017	NEW	$468,380
														Subtotal = $468,380

Grand Total All Awards = $2,495,977

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Track 2 - Assistance: Greater New Haven AHC Project: Tailored Community Referrals and Intensive Navigation for Randomized qualified Beneficiaries w/2 or more ED visits in Prior Yr and 1 or more HRSNs

Award Number: 1P1CMS331558

ORGANIZATION: HEALTH CARE FINANCING ADMINISTRATION, OFFICE OF ACQUISITION AND GRANTS

OPDIV: CMS

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: DEMONSTRATION

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