Accountable Health Communities (AHC)...Accountable Health Communities Model Intervention Approaches:...
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Accountable Health Communities (AHC) Model Overview and Requirements
Transcript of Accountable Health Communities (AHC)...Accountable Health Communities Model Intervention Approaches:...
Accountable Health Communities (AHC)
Model Overview and Requirements
• 5-year model
• Will systematically identifying and addressing the health-
related social needs of community-dwelling Medicare and
Medicaid beneficiaries impacts health care quality, utilization
and cost?
Model Performance Metrics
• Healthcare utilization: emergency department visits, inpatient admissions, readmissions and utilization of outpatient services
• Total cost of care
• Provider and beneficiary experience
Accountable Health Communities ModelIntervention Approaches:
Summary of the Three Tracks
Track 1 Awareness – Increase beneficiary awareness of available communityservices through information dissemination and referral
Track 2 Assistance – Provide community service navigation services to assisthigh-risk beneficiaries with accessing services
Track 3 Alignment – Encourage partner alignment to ensure that communityservices are available and responsive to the needs of beneficiaries
Alignment
Assistance
Awareness
Total Funding
• $12 million to 12 bridge organizations to implement Track 1 – Awareness intervention, $200,000/year
• $30.84 million to 12 bridge organizations to implement Track 2 – Assistance intervention, $514,000/year and
• $90.20 million to 20 bridge organizations to implement Track 3 – Alignment intervention, $902,000/year
FUNDING
Model Participants
• Bridge organization
• At least one state Medicaid agency
• Community service providers that have the capacity to address thecore health-related social needs
• Clinical delivery sites, including at least one of each of the followingtypes:
– Hospital
– Provider of primary care services
– Provider of behavioral health services
• ADVISORY COMMITTEE
Track 3 – Alignment Evaluation Diagram
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Alignment Intervention Pathway
Secondary Unit of Analysis
Not enrolled in Track 3 intervention
Receives Alignment
Intervention and Usual Care
Screening for health-
related social needs
Receives Awareness Intervention and Usual
Care
(+) Screen: Any health-
related social need present
High risk (> 2 ED visits
within 12months)
Lower risk(< 2 ED visits
within 12months)
(-) Screen:No health-
relatedsocial need
Partner Alignment(Quality Improvement
Approach)
+
CommunityReferral
Summary
+
CommunityService
Navigation
Risk
Stratified
CommunityReferral
Summary
Usual Care
Beneficiary enters Clinical Delivery Site
1. HOSPITAL2. PROVIDER OFFICE/CLINIC3. BEHAVIORAL HEALTH FACILITY
Selection Criteria
The selection criteria for applications will be based on the prospective bridge organization’s ability to:
• Meet eligibility and application requirements for the track chosenby the applicant organization
• Demonstrate commitment, collaboration, and engagement ofcommunity stakeholders
• Provide required social needs data and Medicare and Medicaid claims data on beneficiaries in the model to CMS and its contractors
• Demonstrate readiness to implement the intervention
Funding OpportunityAnnouncement Posting Date:
January 5, 2016
Letter of Intent to Apply Due:February 8, 2016
Electronic Cooperative AgreementApplication Due:
May 18, 2016 (1 PM ET)
Anticipated Issuance of Notices ofAward: December 2016
Anticipated Start of Cooperative AgreementPeriod of Performance: January 2017
Accountable Health Communities Model Dates
Atlanta Accountable Health Community Model – ELECTRONIC SCREENING OPTION
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ELECTRONIC OPTION
PATIENT IS ELIGIBLE
INTRODUCE SCREENING PURPOSE AND
PROTOCOL
Screening ends
HEALTH-RELATED
SOCIAL NEEDS IDENTIFIED
THANK YOU FOR YOUR
PARTICIPATION
END OF INTERVENTION
Yes
ASSISTANCE -TAILORED
COMMUNITY REFERRAL SUMMARY
RISK STRATIFICATION
INDIVIDUAL ACTION PLAN TO REMOVE BARRIERS TO ACCESSING COMMUNITY
RESOURCES
High Risk
# Eligible and Screened by
Clinical Delivery Site
# w/o Health-related Social Needs
Personal Interview w/in 48 hours.
UNRESOLVED
COMPLETED
# with Health-related Social Needs
# Lower Risk
# High Risk
Screening begins
No
NAVIGATION
Action Plan successful and health-related social needs met
Failure to respond after 3 attemptsUnmet due to lack of available resources
Lower Risk
Navigation Assistance
# accept# decline
# CONSENTS# OF DECLINES
Of those consenting
Of those with
health-related social needs
Of those at high risk
# health-related social needs by core need
(food, housing, transportation, utility, interpersonal violence)
# Completeed# Unresolved
(unable to reach, resources unavailable)
Of those receiving
assistance
Atlanta Accountable Health Community Model – SCREENING ASSISTANCE OPTION
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ARRIVAL AT CLINICAL
DELIVERY SITE
SCREENING ASSISTANCE
PATIENT IS ELIGIBLE
INTRODUCE SCREENING PURPOSE AND
PROTOCOL
Screening beginsAssistant assists with data
input on behalf of beneficiary
HEALTH-RELATED
SOCIAL NEEDS IDENTIFIED
THANK YOU FOR YOUR
PARTICIPATION
END OF INTERVENTION
Yes
SCREENING ASSISTANT PROVIDESTAILORED
COMMUNITY REFERRAL SUMMARY
RISK STRATIFICATION
INDIVIDUAL ACTION PLAN TO REMOVE BARRIERS TO ACCESSING
COMMUNITY RESOURCES
# Eligible and Screened by
Clinical Delivery Site
# w/o Health-related Social Needs
Personal Interview w/in 48 hours.
UNRESOLVED
COMPLETED
# with Health-related Social Needs
# Lower Risk
# High Risk
Warm hand-off to Screening Assistant
No
NAVIGATION
Action Plan successful and health-related social needs met
Failure to respond after 3 attempts Unmet due to lack of available resources
Lower Risk
Navigation Assistance
# accept# decline
# CONSENTS# OF DECLINES
Of those Consenting # needing screening assistance
Of those with
health-related social needs
Of those at high risk
# health-related social needs by core need
(food, housing, transportation, utility, interpersonal violence)
# Completeed# Unresolved
(unable to reach, resources unavailable)
Of those receiving
assistance
High Risk
Assistance in understanding the
Navigation Assistance protocol
Warm Hand-off to Navigator
