Accountable Health Community Track 3 - The Mississippi Delta Accountable Health Community - Delta Health Alliance (DHA) and its partners - rural health and federally qualified health clinics, rural hospitals, primary care and behavioral health clinical delivery sites and community-based social service providers - propose implementing an Accountable Health Community (AHC) Track 3 - Alignment project in the Mississippi Delta, one of the historically poorest, universally underserved regions of the United States. We believe this rural, high poverty region provides a unique opportunity for testing the AHC model, because successful implementation of this model in the under-resourced Mississippi Delta would help demonstrate the efficacy and reliability of the AHC intervention. The Mississippi Delta AHC has adopted the following aim by the end of the project period (March 2022): Achieve a 5% reduction in Medicare and Medicaid beneficiaries’ healthcare utilization and costs by more efficiently and effectively addressing their health-related social needs. Using the evidence basis established by CMS, primary drivers required to achieve this aim include: improved awareness of community services and support, increased utilization of community-based services and resources, improved alignment of social services across settings and providers, and a more robust evaluation of health-related social services yielded from this improved coordination. With input and direction from the Mississippi Division of Medicaid, DHA will develop standardized screening and referral protocols, populated with questions developed by CMS, designed to improve patient access to an array of community service providers available to address core health-related social needs (housing, utility needs, food insecurity, interpersonal violence and transportation). This program will meet CHS milestones by screening 75,000 Medicare or Medicaid beneficiaries each year and providing navigation services to at least 5,000 high-risk, community-dwelling beneficiaries per year. DHA requests $4,509,758 over a five-year period which will be used to: (1) develop a community resource inventory of social services; (2) screen community-dwelling beneficiaries to identify their specific unmet health-related social needs; (3) refer beneficiaries to increase awareness of community services; (4) provide navigation services to assist high-risk beneficiaries with accessing community services; and (5) encourage and support alignment between and across clinical and community services. This Mississippi Delta Accountable Health Community will focus on the Delta’s highest need counties (Bolivar, Coahoma, Holmes, Humphreys, Leflore, Sunflower, and Washington) which are among the poorest 2% of all U.S. counties. These rural counties along Mississippi’s northwest border are home to 198,842 total residents, including an estimated 38,036 Medicare enrollees and 94,003 Medicaid enrollees – a total of 132,039 community-dwelling Medicare and/or Medicaid beneficiaries. DHA has recruited 14 clinical delivery sites and 9 community-based service providers to carry out the Mississippi Delta AHC. Partnering clinical delivery sites served over 51% of the area’s community-dwelling beneficiaries in the past 12 month period. Over the past five years, DHA has been involved in a variety of programs designed to improve linkages between high-risk patients and important health and wellness services. DHA currently operates a Care Transitions program with the two hospitals participating in this initiative, to improve care coordination and access to services for patients discharged with chronic illnesses. DHA also operates the Indianola Promise Community, which includes a comprehensive LINKS program (Linking Individuals, Neighborhoods and Kids to Services). LINKS staff work with whole families in Indianola to identify needs, gaps in services, as well as serve as an advocate for children and their parents. DHA also leads the 20+ member Sunflower County Social Services Collaborative, coordinating access to programs.
