Accountable Health Communities

Objectives: The Centers for Medicare & Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (the Innovation Center), will assess whether systematically identifying and addressing the health-related social needs of community-dwelling Medicare and Medicaid beneficiaries, including those who are dually eligible, impacts those beneficiaries’ total health care costs and their inpatient and outpatient utilization. Section 3021 of the ACA authorizes the Innovation Center to design, implement and evaluate innovative payment and service delivery models to improve quality and reduce costs. Rigorous evaluation requirements of the model’s impact influence model design parameters. The Accountable Health Communities (AHC) Model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. This model will support community collaboration to systematically: (1) screen beneficiaries to identify unmet health-related social needs; (2) refer beneficiaries to increase awareness of community services; (3) provide person-centered navigation services to assist beneficiaries with accessing community services to resolve health related social needs; and (4) align clinical and community services to ensure that community services are available and responsive to the needs of beneficiaries. The expectation is that these efforts will lead to a reduction in health care utilization and costs. The funding opportunity announcement (FOA) initially offered three interventions of varying intensity (each referred to as a “track”) to better link beneficiaries to community services: the Assistance Track Intervention, the Alignment Track Intervention or a third opportunity called the Awareness Track. The Awareness Track opportunity has subsequently been withdrawn. The Assistance Track Intervention tests whether assisting beneficiaries with accessing services through community service navigation impacts total health care cost and inpatient and outpatient health care utilization. This intervention offers universal screening of health-related social needs, use of a community resource inventory to connect beneficiaries to available community services, identification of high-risk beneficiaries as part of a smarter spending strategy to target additional resources where they are needed the most, and community service navigation to assist high risk beneficiaries with resolving health-related social needs. The Alignment Track Intervention builds on the intervention of the Assistance Track and tests whether a combination of navigation services at the individual beneficiary level and partner alignment at the community level impacts total health care costs and ED visits and inpatient hospital admissions. This approach recognizes that there are significant barriers to effective integration of the health care delivery systems, governmental public health systems, and the community-based service system due to different cultures, funding streams and data systems. Effective and responsive infrastructures are needed to ensure that community services are available and address the health-related social needs of beneficiaries. The Alignment intervention incorporates innovations included in the Assistance Track and adds structural and financial support designed to foster community-wide realignment of resources to more effectively address beneficiaries’ health-related social needs. Successful applicants were selected to participate in a single track for a five-year period. Although tracks share common design elements, each track’s intervention pathway and underlying hypothesis is distinct.