CMS to Fund 'Accountable Health Communities' Models

The first CMS model to focus on the health-related social needs of Medicare and Medicaid beneficiaries will test ways to link clinical and community services and to address health-related social needs through the use of community health navigators.

Rural and community health advocates have long talked about the need to improve cooperation and coordination with social services providers. This makes sense not only because the end result will be better, cost-effective care. It's also a better use of scarce resources at a time when many rural providers are struggling to keep the doors open.

It now appears that the federal government shares that line of reasoning. The Centers for Medicare & Medicaid Services is offering $157 million in seed money over five years for as many as 44 "bridge organizations" across the nation that will assess their Medicare and Medicaid patients' health-related social needs, refer them to community resources, and assign them to "community health navigators" who will help them through the process.

It's the first model for CMS that focuses on health-related social needs of Medicare and Medicaid beneficiaries. It will test ways to link clinical and community services and to address health-related social needs through community referral, community service navigation, and community service alignment.

"We've known for a long time that an ounce of prevention can be worth a pound of cure. Yet our healthcare system doesn't always encourage prevention, especially around unmet social needs," CMS Deputy Administrators Darshak Sanghavi, MD, and Patrick Conway, MD, wrote on the CMS blog.

"These problems can lead to poor health that requires expensive emergency room visits or hospitalizations. Many social needs, such as housing instability, hunger, and interpersonal violence, affect individuals' health. Yet they may not be detected or addressed during typical, short doctor's visits."

CMS offered this hypothetical scenario to show how the program might work: "A mother comes in to a participating community health center for her child with asthma. During a complete social screening, the center learns the mother has been living in a moldy trailer after fleeing a violent home life. They refer the family to a local safe housing program and legal aid to protect her. The center connects her with these services with the aid of a community health navigator. By helping the family find safe permanent housing, we reduce the frequency of the child's visits to the ER for asthma attacks."

Another scenario could be as simple as finding transportation to a physician's appointment for an elderly patient, or conducting a home fall-risk assessment, or ensuring that a patient's electricity isn't shut off. Each patient comes to healthcare providers with their own set of luggage. (The CMS blog provides more details about how the program might work. The agency is also holding webinars on Jan. 21 and Jan. 27 to explain the application process. Registration is required.)

Sally Beckley, executive director of LifeTime Resources, Inc., in Dillsboro, IN, says the not-for-profit area agency on aging is already providing many of the case management services in its three-county service area that might fall under the Accountable Health Communities project. Still, she likes what she's hearing from CMS.

"I have been very interested in the last five or six years that the federal government is starting to recognize the value of these services," says Beckley. "Up until then there was absolutely no recognition at all, and there has never been a connection between Older Americans Act programs and CMS. They're two different worlds. They don't connect."

Beckley says the walls between health providers and social services will have to be knocked down if the program is to be successful.

"The healthcare world doesn't think in terms of social services, and so it just doesn't even come to mind to begin with, particularly in our rural area where there aren't a lot of options," she says. "That's where the model that we are developing is. Because we are such a rural area, it is very focused on individualized care plans. If we can help the medical community know when to make a referral to us, then we can figure out how to solve their problem. The guts of what we are trying to do is to help the medical community understand the value of what we do and then be creative in trying to find solutions."

Tim Putnam, CEO at Margaret Mary Community Hospital, says providers at the critical access hospital in Batesville, IN "see so many things that negatively impact health when we deliver acute care services that we can't impact."

"From a small community or rural perspective where you don't have a taxi service, transportation comes out as No. 1," he says. "I see a lot of people who are vulnerable and who need someone who can take a patient home from the ED or someone who can help tighten the handrail in their home or help them shop for the right kinds of food or help prepare a meal. Things like that are what help people live a healthier lifestyle."

Putnam says these interventions could be cost effective, but it can't simply be a program where hospitals go it alone.

"It is going to have to be healthcare delivery organizations working closely with other organizations and agencies. That can vary from a council on aging, public health departments, even local churches and other social organizations," he says. "It is not going to be a hospital or a group of hospitals trying to build this infrastructure themselves. It's going to be trying to leverage what already exists out there and create a common work platform."

There are also some practical problems that will have to be ironed out, such as who gets the check, and who gets paid for what. Putnam doesn't think that will present too big an obstacle.

"We're gaining an expertise in that as we get into bundled pricing and the new payment models so it is forcing people to come together and have that discussion," he says. "I can't say it is going to be smooth all the time. People value their services differently, and how to get paid for that will be an interesting discussion. But it is clearly a discussion that we are having more and more now than we were just a couple of years ago."

Putnam says he's interested in the pilot program but he's not ready to commit.

"It will be a discussion I will have with community partners to find out if it is something they'd be interested in," he says. "If they are, it is something we should look into. But without interest from other parties we would not want to do it alone. That's not the way it needs to happen."