Accountable Health Communities Model
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www.hcgc.org January 29, 2016 Accountable Health Communities Model Exploring the Greater Columbus Region’s readiness to pursue a CMS funding opportunity.
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Transcript of Accountable Health Communities Model
www.hcgc.org
January 29, 2016
Accountable Health Communities ModelExploring the Greater Columbus Region’s readiness to pursue a
CMS funding opportunity.
www.hcgc.org
Webinar Objectives
• Explore which track appears to be a good fit for Greater Columbus and what would best align with work taking place in the region.
• Explore the readiness of medical neighborhood partners to pursue CMS funding and, if funded, participate in an AHC project.
• What organization is best suited to serve as the bridge organization in Greater Columbus?
www.hcgc.org
Today’s Agenda
• Review the AHC Model Overview
• Explore the Three Funding Tracks
• Explore the Roles of AHC Model Participants
• Participant Discussion and Feedback
www.hcgc.org
Model Background
The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care.
www.hcgc.org
Model Background
Bridge Organization
Evaluation
Referral Infrastructure
Screening Tools
Care Coordination
Fiscal Role
Providers -1 PCP
-1 Hospital -1 Behavioral Health
State Medicaid Agency
Social Service Agencies
What will it take to advance AHC in Greater Columbus?
www.hcgc.org
Key Dates
• LOI Due (Optional & Non-Binding): February 8, 2016
• Proposal Due: March 31, 2016
• Grant Awarded: November 1, 2016
• Grant Period: January 1, 2017 – December 31, 2021
www.hcgc.org
Key Definitions
• Community-Dwelling Beneficiary = Medicare or Medicaid beneficiary, regardless of age, who is not residing in a correctional facility or long-term care institution when accessing care at a participating clinical delivery site. Includes Medicaid and Medicare advantage plans.
• Health-Related Social Need = refers to community services need that can be linked to health care, including the cost of care and inpatient and outpatient utilization of care.
www.hcgc.org
Health-Related Social Needs
Core Needs (Required)Housing InstabilityUtility NeedsFood InsecurityInterpersonal ViolenceTransportation
Supplemental NeedsFamily & Social SupportsEducationEmployment & IncomeHealth BehaviorsOthers
Grantees will be required to screen beneficiaries for all of the core health-related social needs.
Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.
www.hcgc.org
What does the model fund?
Over a five-year performance period, CMS will implement and test a three-track model:
• 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 beneficiaries
www.hcgc.org
Funding Opportunities
• Track 1 - Awareness (12 Awards) • Up to $1 million over 5 year test period
• Track 2 - Assistance (12 Awards)• Up to $2.57 million over 5 year test period
• Track 3 - Alignment (20 Awards)• Up to $4.51 million over 5 year test period
www.hcgc.org
Exploring the Funding Tracks
Track 1 - Awareness
www.hcgc.org
Exploring the Funding Tracks
Beneficiary Selection Process
www.hcgc.org
Exploring the Funding Tracks
Track 2 - Assistance
www.hcgc.org
Exploring the Funding Tracks
Track 3 - Alignment
www.hcgc.org
Partner Roles
Bridge Organization
• Partner w/ a State Medicaid Agency
• Partner w/ clinical providers to provide required AHC interventions and implement a CMS screening tool
• Develop and maintain a database of community services. Updated every 6 months.
• Manage grant funding
• Lead the grant application process
• Track 2 & 3 – Coordinate community service navigation
• Track 3 - Partner w/ community service providers to align quality improvement
www.hcgc.org
Partner Roles
State Medicaid Agency
• MOU w/ Bridge Organization
• Data collection and reporting
• Sustainability planning
• Annual Intervention review to ensure services are not duplicative
• Annual review of the AHC intervention and a letter of support
• Track 3 – Participate on Advisory Board
www.hcgc.org
Partner Roles
Clinical Providers
• At least 1 primary care provider, 1 hospital system, 1 behavioral health provider
• MOU w/ Bridge Organization
• Screen at least 75,000 Medicaid/Medicare beneficiaries per year for health-related social needs. Screening tool provided by CMS
• Track 3 Only – Reach at least 51% of Medicaid and Medicare beneficiaries served by participating providers in the geographic region (geographic region defined by applicant)
www.hcgc.org
Partner Roles
Community Service Providers
• MOU w/ Bridge Organization
• Track 1 & 2 – Receive referrals from clinical providers
• Track 3 – Receive referrals and actively participate in service alignment on quality improvement
www.hcgc.org
Model Background
Bridge Organization
Evaluation
Referral Infrastructure
Screening Tools
Care Coordination
Fiscal Role
Providers -1 PCP
-1 Hospital -1 Behavioral Health
State Medicaid Agency
Social Service Agencies
What will it take to advance AHC in Greater Columbus?
www.hcgc.org
Accountable Health Communities
Questions
www.hcgc.org
Webinar Objectives
• Explore which track appears to be a good fit for Greater Columbus and what would best align with work taking place in the region.
• Explore the readiness of medical neighborhood partners to pursue CMS funding and, if funded, participate in an AHC project.
• What organization is best suited to serve as the bridge organization in Greater Columbus?
www.hcgc.org
Exploring the AHC Model
Exploratory Question #1
• From your unique perspective, should the Greater Columbus region pursue the AHC Model grant collaboratively?
www.hcgc.org
Exploring the AHC Model
Exploratory Question #2
• What track aligns with work taking place in the Greater Columbus region?
www.hcgc.org
Exploring the AHC Model
Exploratory Question #3
• What organization in the community is best-suited to serve as the bridge organization?
www.hcgc.org
Partner Roles
Bridge Organization
• Partner w/ a State Medicaid Agency
• Partner w/ clinical providers to provide required AHC interventions and implement a CMS screening tool
• Develop and maintain a database of community services. Updated every 6 months.
• Manage grant funding
• Lead the grant application process
• Track 2 & 3 – Coordinate community service navigation
• Track 3 - Partner w/ community service providers to align quality improvement
www.hcgc.org
Next Steps
If you are interested in learning more, please contact Michelle Missler ([email protected])
or John Leite ([email protected]).
Funding Opportunity Page: https://innovation.cms.gov/initiatives/AHCM
