What do CMS and $157 Million Have to Do with Community Health?


For vulnerable individuals with complex health issues, what happens after seeing their primary care physician is critical to ensuring their overall health. According to the Centers for Medicare and Medicaid, many of the biggest drivers of health and healthcare costs are beyond the scope of healthcare alone. Many of these drivers are health-related social needs, such as:

  • Housing instability
  • Food insecurity
  • Utility needs
  • Interpersonal violence
  • Transportation needs

Traditionally health and social service providers have operated separately and have not collaborated to address all aspects of an individual’s health. Many states have Medicaid Waiver programs that are designed to test new methods for providing whole-person care, however, they are unique to each state. In an effort to bridge this gap and improve population health nationwide, the CMS Innovation Center announced that it will give up to $157 million in grant funding to 32 organizations across the country to participate in its 5-year Accountable Health Communities Model. The organizations include county governments, universities, hospitals, nonprofit organizations, and health departments.

The Accountable Health Communities Model encourages community and healthcare providers to engage in population health management strategies which address the underlying social factors contributing to poor health for Medicare and Medicaid beneficiaries. According to Dr. Patrick Conway, CMS Deputy Administrator for Innovation & Quality, “We know that innovation at the state and community level is essential to improve health outcomes and lower costs. In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country.”

The model comprises 3 tracks: Awareness, Assistance, and Alignment. The goal of each track is to reduce unnecessary healthcare utilization, drive down spending, and improve individual outcomes and quality of care. All participating organizations will function as a “hub” connecting members of their community to health-related social services in addition to primary care. The 32 providers announced by CMS are participating in the Assistance and Alignment tracks and an additional 12 Awareness Track participants will be announced later this summer.  Here is a brief description of each:

Awareness Track

The Awareness Track is designed to lower healthcare utilization and improve quality of care for high-risk individuals by increasing the awareness of available community services through information dissemination.

Assistance Track

In addition to increasing awareness, the Assistance Track encourages communities to link high-risk beneficiaries with navigation services which help them access care for health-related social needs. In Indianapolis, CMS awarded the Community Health Network Foundation more than $2.5 million to address the social needs of Medicare and Medicaid recipients on the east side of Indianapolis. The Community Health Network Foundation will specifically partner with the Eastside Redevelopment Committee to address these social needs, including food assistance and job training.

Alignment Track

The Alignment Track includes an additional third component — it also encourages community-level partner alignment to ensure needed services and supports are available and responsive to beneficiaries’ needs. This is accomplished through an advisory board focused on continuous quality improvement, including ensuring community services are available and data is shared. The Camden Coalition of Healthcare Providers in New Jersey provides a good example. The coalition has launched the national Center for Complex Health and Social Needs to bring experts from various fields together to collaborate on ways to improve care for complex patients with multiple social needs. Another example is Oregon Health & Science University whose pilot program targets rural healthcare costs and utilization by partnering with local community organizations and researchers.

CMS officials are optimistic that the Accountable Health Communities Model will provide a cost-effective approach to improving overall health for Medicare and Medicaid beneficiaries in the participating communities. Eccovia Solutions is excited about the potential impact this program may have on communities across the country. We will be following the progress of these communities and providing updates in the future.

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