CMS’ goal for the model is to support local communities in addressing the health-related social needs of Medicare and Medicaid beneficiaries “by bridging the gap between clinical and community service providers.”  The model seeks to test whether total cost of care and health care utilization can be positively impacted by systematically identifying and addressing beneficiaries’ health-related social needs.

The model provides funding for testing three scalable approaches or tracks:  

  • Assistance Track – Provide community service navigation services to assist high-risk beneficiaries with accessing services to address health-related social needs
  • Alignment Track – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries
  • Awareness Track – Increase beneficiary awareness of available community services through information dissemination and referral (Awards to be announced July 2017)

Similar to the integrated service vision that LeadingAge is developing, this model has designated “bridge” organizations that serve as community hubs that form and coordinate consortia that:

  1. Identify clinical delivery site partners to screen community-dwelling beneficiaries for health-related social needs and make referrals to community services to address the identified needs;
  2. Provide community service navigation by coordinating and connecting community-dwelling beneficiaries to community service providers;
  3. “Align model partners to optimize community capacity to address health-related social needs” (Alignment Track only).

CMMI will assess the efficacy of the Accountable Health Community model using the following metrics: total cost of care, emergency department use, and hospital readmission rates.

Accountable Health Communities are located in the following states: AZ, CO (2), CT (3), GA, IL, KY, MI, MN (2), MS, NV, NJ(2), NM, NY(2), OH(2),  OK, OR, PA, RI, TN, MD, IN, TX (2), VA, WV

Community-based organizations, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and not-for-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers were all eligible to apply for grant funding to test one of the model’s tracks.  LeadingAge members in Ohio are participating in one of the approved programs.