Health and Fitness

First-ever CMS Innovation Center Pilot Project to Test Improving Patients’ Health by Addressing Their Social Needs

$157 million in funding will bridge clinical care with social services

Washington, DC–(ENEWSPF)–January 5, 2016.  The Department of Health and Human Services today announced a new funding opportunity of up to $157 million to test whether screening beneficiaries for health-related social needs and associated referrals to and navigation of community-based services will improve quality and affordability in Medicare and Medicaid. Many of these social issues, such as housing instability, hunger, and interpersonal violence, 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.

The five-year program, called the Accountable Health Communities Model, is the first Centers for Medicare & Medicaid Services (CMS) Innovation Center model to focus on the health-related social needs of Medicare and Medicaid beneficiaries, including building alignment between clinical and community-based services at the local level. The goal of this model is that beneficiaries struggling with unmet health-related social needs are aware of the community-based services available to them and receive assistance accessing those services.

“We recognize that keeping people healthy is about more than what happens inside a doctor’s office, and that’s why, for the first time, we are testing whether screening patients for health-related social needs and connecting them to local community resources like housing and transportation to the doctor will ultimately improve their health and reduce the cost to taxpayers,” said HHS Secretary Sylvia M. Burwell. “The Accountable Health Communities model is yet another step towards building a health care system that results in healthier people and stronger communities and spends our health care dollars more wisely.”

Award recipients under this model, referred to as “bridge organizations,” will oversee the screening of Medicare and Medicaid beneficiaries for social and behavioral issues, such as housing instability, food insecurity, utility needs, interpersonal violence, and transportation limitations, and help them connect with and/or navigate the appropriate community-based services. For example, a patient who isn’t taking his medication because he or she lacks transportation to the pharmacy would be referred to federal, state or local assistance programs. Some bridge organizations will assist beneficiaries in applying for community-based services, such as the Low Income Home Energy Program, which can provide much-needed assistance with utility bills and allow beneficiaries to maintain their medication supply rather than having to choose between maintaining their health or paying their heating bill.

“For decades, we’ve known that social needs profoundly affect health, and this model will help us understand which strategies work to help improve health and spend dollars more wisely,” said Dr. Patrick Conway, CMS Deputy Administrator and Chief Medical Officer. “We will learn how health and health care improvements can be achieved through strong partnerships and linkages at the community level.”

The Affordable Care Act provides tools, such as the Accountable Health Communities Model, to move our health care system toward one that rewards doctors based on the quality, not quantity of care they give patients. Today’s announcement is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality. In January 2015, HHS announced the ambitious goal of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016 and 50 percent of payments by 2018. More than 4,600 payers, providers, employers, patients, states, consumer groups, consumers and other partners have registered to participate in the Health Care Payment Learning and Action Network, which was launched to help the entire health care system reach these goals.

Model Description

Thanks to funding provided under the Affordable Care Act, the Accountable Health Communities Model will support up to 44 bridge organizations, which will deploy a common, comprehensive screening assessment for health-related social needs among all Medicare and Medicaid beneficiaries accessing care at participating clinical delivery sites.

The model will test three scalable approaches to addressing health-related social needs and linking clinical and community services – community referral, community service navigation, and community service alignment. Bridge organizations will inventory local community agencies and provide referrals to those agencies as needed. They may also provide intensive community service navigation such as in-depth assessment, planning, and follow-up until needs are resolved or determined to be unresolvable for high-risk beneficiaries.

The pilot allows participants to assess community services and encourage partner alignment to ensure these services are available and responsive to the needs of beneficiaries. This continuous quality improvement approach includes organizing an advisory board and data sharing to inform a gap analysis and quality improvement plan.

To measure the effectiveness of the model on impacting total cost of health care utilization and quality of care, the primary evaluation will focus on reduction in total health care costs, emergency department visits, and impatient hospital readmissions.

Eligible applicants for the Accountable Health Communities model are community-based organizations, 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. Applications will be due in early 2016 and CMS anticipates announcing awards in the fall of 2016.

To view a fact sheet on the Accountable Health Communities Model or for more information on the Accountable Health Communities Model, including the Funding Opportunity Announcement, please visit: