- CMS has named 32 participants to serve as local “hubs” linking clinical and community services under its Accountable Health Communities model.
- Twelve organizations will participate in an Assistance Track, helping high-risk Medicare and Medicaid beneficiaries navigate and access community services. In addition to the navigation service, the 20 organizations in an Alignment Track will encourage community-level partnerships to ensure that targeted services are available and responsive to patients needs, the agency said.
- The 32 organizations are spread across 193 counties in 23 states, both urban and rural, and include hospitals, universities, health departments and other local organizations.
Among the groups selected for the AHC Assistance Track is Community Health Network Foundation in Indianapolis, which will work with Eastside Redevelopment Committee to reduce emergency room utilization in East Indianapolis. Forty percent of those living in the community are on Medicaid, and its ER utilization rate is above the national average, CMS says.
Oregon Health & Science University, in the AHC Alignment Track, will collaborate with clinical sites, community service providers and local health departments in nine rural counties to reduce healthcare utilization and costs to more than 300,000 Medicare and Medicaid recipients.
The five-year pilot projects will get underway May 1.
Provider and payers are using tools such as GIS to track and trend health data, providing insights into high-risk populations and helping to prioritize areas for interventions. With the move to value-based care models, healthcare organizations are also realizing that they can’t do it all on their own and some are partnering with local agencies and community groups to promote healthy eating, screenings and other preventive services.
“The traditional ‘silos’ of medical, behavioral and social services can’t meet the needs of our population alone,” Jim Hickman, CEO of California-based Better Health East Bay, told Healthcare Dive last November. “Partnerships, enabled by technology and amplified by data-sharing, are the first step in changing the way we deliver care.”