93.650: Accountable Health Communities

93.650

Inactive

Centers for Medicare and Medicaid Services (CMS) [HHS]

Aug. 8, 2022

Aug. 8, 2022

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 The Awareness Track opportunity has subsequently been withdrawn.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 will test 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.

A - Formula Grants

Community-based organizations, individual and group healthcare practices, hospitals and health systems, institutions of higher education (IHE), local government entities, tribal organizations and for-profit and not-for-profit local and national entities with the capacity to develop and maintain relationships with clinical delivery sites and community service providers. Applicants from all 50 states, United States territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin Islands), and the District of Columbia were eligible to become bridge organizations. Eligible IHEs were limited to college and university health care affiliates delivering clinical services, such as community-based clinics, hospital networks, and health systems. Local government entities included, but were not limited to, local units of state and regional agencies where such classifications exist, local and tribal health departments, local public housing authorities, Indian housing authorities, and local community service agencies. Local government entities excluded state Medicaid agencies.

Potential applicants were limited to the eligible entities described in the sections above. Successful applicants provide intervention services to community-dwelling Medicare and Medicaid beneficiaries, including dually eligible beneficiaries. Community-dwelling beneficiaries include beneficiaries not residing in a correctional facility or long-term care institution (e.g., long-stay nursing homes) when accessing clinical care at a participating clinical delivery site. Awardee applications described the target populations, geographic areas, and communities that are the focus of the AHC intervention, the current quality and beneficiary experience outcomes, including current needs assessments of health-related social needs, and specific targets to be impacted by the AHC intervention.

https://sam.gov/fal/32adcc6c34364c15927bc23dbbd1086c/view