Accountable Health Communities: A Promising Model

Comprehensive Community Wellness

In any discussion of the skyrocketing costs of healthcare and inadequate accompanying improvements in outcomes, the importance of analyzing the social determinants of health cannot be overstated. In looking at the population of “super-utilizers” of medical services and resources, the approximately 5% of Americans who account for 50% of healthcare spending, one would likely see strong correlations to deficiencies in one or more social determinants of health, including factors such as food, housing, and financial security, as well as language barriers and mental and behavioral health. And indeed, study after study will show that these factors that cannot be treated inside an emergency room are strong predictors of chronic illness and frequent catastrophic medical emergencies.

To address this, CMS committed funding to the Accountable Health Communities (ACH) Model. The ACH model was devised around a goal of improving outcomes and reducing healthcare costs for Medicaid and Medicare beneficiaries by focusing community resources toward alleviating poor status in the social determinants of health of the most vulnerable individuals. The focus of the model is centered on four aspects:

  • Identifying unmet health-related social needs among beneficiaries in the community
  • Referring beneficiaries to various community services, helping to spread awareness of what resources are available to them
  • Helping high-risk beneficiaries navigate and access community services
  • Aligning clinical and community services to ensure community services are available and responsive to beneficiaries’ needs

While the first point is applicable in all cases, the model will be divided into three tracks following the three final points: an Awareness track, an Assistance track, and an Alignment track, respectively.

The model, implemented in 2016, is intended to run for five years, during which it will help bring together concerned organizations with the aim of matching beneficiaries to the community services and resources available, particularly where they may address gaps in their stability with the social determinants of health.

At the end of the five-year period, the results will be evaluated to determine whether and to what extent meeting these health-related social needs improve healthcare outcomes and costs.

Across the United States, more than 30 organizations in 23 states are participating in this model.

One such organization, the Baltimore City Health Department, where nearly 60% of the population are Medicaid or Medicare beneficiaries, was selected by CMS to participate in the Alignment track. Although it is too early to see results, Baltimore has revealed how they plan to proceed.

Baltimore’s approach to enacting this model centers around broad goals and narrow goals. The broad goals identified on the organization’s website are as follows:

  • Effectively identify patients’ health related social need and connect them, based on those needs, to critical resources successfully
  • Create unified systems and technology to support all the stakeholders involved in screening and resource navigation
  • Conduct back-end data collection to drive ongoing quality improvement
  • Make the case that integration of social needs into clinical care is effective and cost-effective

While these are certainly good goals in principle, and these certainly align with the AHC’s mission, they are broad enough to be difficult to gauge. Therefore, to measure the success of the above goals, Baltimore has set the following narrow, quantifiable goals:

  • Screening approximately 40,000 beneficiaries every year
  • Referring 2,935 beneficiaries to a centralized AHC hub for navigation to services and providers
  • In cases where individuals don’t get navigation, community referrals via a technology platform will fill this need
  • Once referrals are made, tracking those referrals to follow up and determine whether they were successful in securing the needed services
  • Developing and adopting workflows and a technology system capable of handling the data sharing and community coordination infrastructure necessary to accomplish these goals

To achieve these goals, the Baltimore City Health Department will work in tandem with ten hospitals, including Johns Hopkins, who will participate by forming a design and community advisory board, screening and referring beneficiaries, and sharing their to ensure that progress is in fact being made, and to keep track of the massive undertaking of tracking individuals and the services provided them.

Meanwhile, services organizations including community colleges, AIDS/HIV care, and behavioral health specialists have likewise partnered with the Baltimore City Health Department to focus more on the social determinants of health.

Baltimore is just one of many lead agencies across the country participating in this experiment. The initiative has already seen one interesting if unexpected outcome—namely, CMS dropped the Awareness track as it did not receive sufficient applications, so the experiment will proceed limited to the Assistance and Alignment tracks. As social and healthcare services are knit together, united by a strong care coordination platform and a community that is aware of and focused on addressing the social determinants of health, it will be fascinating to see if the results bear out the hopeful hypothesis upon which this experiment was built.

Be sure to check back here for updates as Baltimore and other participants make progress toward establishing accountable health communities.


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