The Centers for Medicare and Medicaid Innovation (CMMI) have announced the availability of funding for a new model for improving health care quality and reducing health care costs, called Accountable Health Communities.  The model will focus on the health-related social needs of Medicare and Medicaid beneficiaries and test whether screening, referrals, and navigation of community-based services will improve quality and affordability. Many of these social issues, such as housing instability, hunger and food insecurity, interpersonal violence, and transportation limitations, affect individuals’ health, yet they may not be detected or addressed during typical health care-related visits. Over time, these unmet needs may increase the risk of developing chronic conditions and reduce an individual’s ability to manage these conditions, resulting in increased health care utilization and costs.

Over a five-year period, CMS will implement and test a three-track model based on promising service delivery approaches. Each track features interventions of varying intensity that link beneficiaries with community services through Accountable Health Communities “bridge organizations”:

Track 1 Awareness – Increase beneficiary awareness of available community services through information dissemination and referral

Track 2 Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services

Track 3 Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries

Each of the tracks requires the award recipient to serve as a hub responsible for coordinating efforts to:

  • Identify and partner with clinical delivery sites (CDS) (e.g., clinics, hospitals);
  • Conduct systematic health-related social needs screenings and make referrals for all eligible Medicare and Medicaid beneficiaries;
  • Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs and who are randomized to the intervention group to community service providers that might be able to address those needs; and
  • Align model partners to optimize community capacity to address health-related social needs (Track 3 only).

CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by Medicare and Medicaid beneficiaries as a result of their participation in any of the three intervention tracks. Award recipients may only use their award monies to fund interventions to connect beneficiaries with those offering such community services.

Eligible applicants are community-based organizations, healthcare provider practices, 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.  Medicare Advantage and Program of All-inclusive Care for the Elderly (PACE) organizations cannot serve as bridge organizations, but may otherwise partner with bridge organizations to participate in the model.  Applicants may apply to participate in one or two tracks, but successful applicants will be selected to participate in a single track only. Each track will run for a five-year period.

CMMI is using its authority under section 3021 of the Affordable Care Act to test this model.  Up to $157 million will be available to fund up to 44 five-year pilot projects (12 in Track 1, 12 in Track 2, and 20 in Track 3), with awards ranging between $1 million and $4.5 million.  Required, non-binding letters of intent are due by February 8, 2016 and applications are due by March 31, 2016.  Cooperative agreement awards will be announced in the fall of 2016, with the pilot projects to begin January 1, 2017.

Here is the complete Funding Opportunity Announcement:

Link to Original Source (use the View Original Version option)

CMS is hosting a webinar about the model and funding opportunity on January 21, 2016, to be repeated on January 27.

CMS officials also authored an article published today in the New England Journal of Medicine describing the model:

Link to Original Source

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