A new accountable care program from the Centers for Medicare and Medicaid Services seeks to deepen support for Medicare and Medicaid beneficiaries by addressing social needs, such as help with housing, food, interpersonal violence issues, utilities and transportation.

Participating organizations, 32 to start, will have to rely heavily on data analytics, according to information from CMS.

One of the top goals is to optimize community capacity to address health-related social needs through quality improvement, data driven decision making, and coordination and alignment of community-based resources.

The organizations participating, known as AHC Communities, also will need to develop and regularly update comprehensive databases containing information on providers that may be able to address health-related social needs. Participants further are expected to collect and share data on beneficiaries to support monitoring of and evaluation of how well needs are being met.

CMS last year issued a funding opportunity for the Accountable Health Communities model, with three tracks, to support local communities in better supporting local needs. The first track, called the AHC Awareness Track, will focus on increasing beneficiary awareness of available services. CMS is starting the program by launching the second and third tracks with 32 participating community organizations and healthcare delivery systems in a large pilot program, with the Awareness Track coming this summer.

The AHC Assistance Track will support community services to identify high-risk beneficiaries and the services they need. The AHC Alignment Track also will provide help in accessing services while working to better align the services to ensure they are available and meet the right needs.

Patrick Conway, MD
Patrick Conway, MD

“We know that innovation at the state and community level is essential to improve health outcomes and lower costs,” says Patrick Conway, MD, CMS deputy administrator for innovation and Quality. “As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries and their families and caregivers.”

Also See: 10 top providers of ACO services

Community Health Network Foundation in Indianapolis, for example, is participating in the AHC Assistance Track. The foundation has partnered with the Eastside Redevelopment Committee of 50 businesses and community organizations offering workforce development and educational services with the hope of reducing emergency room utilization that is above the national average by helping beneficiaries access alternative services.

Oregon Health & Science University is working in the AHC Alignment Track with 50 rural provider sites, community services and health departments. OHSU also is working with the Oregon Rural Practice-based Research Network of clinicians, community groups and universities to reduce rural health disparities.

Organizations participating in the new ACO program are available here. More information on the program is here.

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