Providers and payers are increasingly addressing the health-related social needs (HRSNs) of their patients to improve outcomes, reduce costs, and address health disparities. As this practice takes hold in the field, the landmark Accountable Health Communities (AHC) Model test that launched in 2017 has now ended. AHC was the Centers for Medicare and Medicaid Services’ (CMS’) first model test focused on evaluating HRSN screening, referral, and navigation. It was built on emerging interventions in Accountable Care Organizations (ACOs), Medicaid Managed Care, Medicaid health homes, and home and community-based services programs.
Early evidence from the AHC Model is promising, and there are many lessons to share as we aim to continue addressing HRSNs and social determinants of health for Medicare and Medicaid beneficiaries. In this article, we bring together key evaluation findings to date and promising practices that providers and payers can implement to address HRSNs in their patient populations and communities. We also describe emerging themes for how AHC Model participants, called bridge organizations, plan to scale and sustain the model interventions and how lessons learned are being embedded across CMS.
Exhibit 1: Pathways to achieving AHC Model outcomes
Definitions: AHC = Accountable Health Communities; CQI = continuous quality improvement; HRSN = health-related social need.
Source: Accountable Health Communities Model First Evaluation Report
What We’ve Learned So Far
The AHC Model offers a unique opportunity to understand key challenges and facilitators for effective screening, referral, community service navigation, and clinical-community collaboration. The twenty-eight bridge organizations that implemented the AHC Model are diverse, including community-based organizations, payers, health information exchanges, hospitals, integrated health systems, and others. They covered 328 counties in 21 states, including 7 of the 10 largest US cities and rural areas in Colorado, Kentucky, New Mexico, Oklahoma, Oregon, Virginia, and West Virginia. In December 2020, CMS released the first of four planned evaluation reports for AHC, and additional resources and case studies are also available to share what we learned.
Screening And Referral
All AHC bridge organizations and clinical partners used the AHC HRSN Screening Tool to universally screen Medicare and Medicaid beneficiaries for food insecurity, housing instability, transportation problems, utility difficulties, and interpersonal violence. Screening occurred across various clinical settings such as emergency rooms, physician practices, and behavioral health clinics, using different types of staff, data platforms, and modalities (e.g., paper, tablets, and patient portals). As of June 2022, more than 1.1 million unique patients had been screened within the model, based on internal CMS data.
Most sites used a combination of existing staff and newly hired screening staff including community health workers. Hiring dedicated screening staff increased clinical site participation by reducing burden among existing staff, but it may have limited integration as clinicians were not always aware of screening results, either because the results were not part of the electronic health record system or clinicians did not review the information.
CMS granted implementation flexibilities that were also critical to gaining buy-in and allowed the bridge organizations to adapt during the COVID-19 public health emergency. As the ability to conduct screening in person became limited, participants were able to move to telephonic screening, and one awardee—the Denver Regional Council of Governments—launched an email campaign to conduct HRSN screening remotely.
Over 35 percent of patients screened reported at least one HRSN and were eligible for referral to community services. Bridge organizations reported that the systematic screening across five core domains expanded existing social needs referral infrastructure by making it more routine across care settings and staff. Bridge organizations maintained community resource inventories for referrals by leveraging pre-existing directories and various technology platforms.
Community Service Navigation
AHC navigation included at least monthly outreach from navigators to patients to learn more about their HRSN(s) and identify barriers to resolving them and progress toward a person-centered action plan to connect with community services to resolve their needs. The eligibility criteria for navigation services—at least one HRSN and self-report of 2 or more emergency department visits in the prior 12 months—effectively identified high-cost, high-use beneficiaries, many of whom were racial and ethnic minorities and had multiple HRSNs. As of June 2022, internal CMS data show more than 137,000 patients accepted navigator help connecting to resources for their HRSN(s) through the model. Acceptance of services has been much higher than anticipated (more than 80 percent of those eligible), and patients reported that over 92,000 of their HRSNs were resolved through the model, according to internal data through June 2022.
Initial findings showed nearly 60 percent of patients eligible for navigation had 2 or more HRSNs. Beyond this complexity of cases, other challenges to navigation included staff turnover, patient mental health needs, and slow responses from community service providers (CSPs). Many awardees found they needed more navigators and more training than anticipated. Bridge organizations and their partners provided additional supports to navigators, including trainings to strengthen their relationship with CSPs and activities to promote shared learning and self-care. Successful navigation is challenging, and continuous quality improvement efforts like those described in case studies from St. Joseph’s Hospital Health System and Health Quality Innovators can identify strategies to improve effectiveness.
Participants used multiple strategies to improve patient engagement, such as tailored scripting and culturally congruent communications approaches, quality improvement techniques such as journey mapping, and technology-enabled outreach, particularly as COVID-19 forced changes to in-person engagement strategies. To improve navigation, participants used warm hand-offs after screening, employed community health workers as navigators, and supported beneficiaries using such techniques as motivational interviewing and trauma-informed approaches.
It was difficult to track navigation and resolution outcomes. Patient needs are sometimes left unresolved due to insufficient community resources, especially for housing and transportation. The model did spur innovative community alignment work aimed at addressing availability of needs. But going forward, this work will require significant trust and skill-building and will take time to implement.
Clinical And Community Collaboration
One aim of the AHC Model was to catalyze trusted partnerships between CSPs and health care entities, which have been difficult to build and maintain despite being an important component of high quality and high value care. All bridge organizations served as integrators to convene CSP and health care partners across multiple facets of the model.
Bridge organizations worked with CSPs to better understand community capacity to address HRSNs. They also identified solutions connected to the experience of and insights from the communities themselves. For example, bridge organizations such as Ballad Health, a regional health care system, and United Healthcare Services, a payer, both conducted root cause analyses with community input that helped to better understand and address the impact of structural issues, such as a shortage of affordable housing, on their community’s health and social needs.
The Health Collaborative, a health information exchange, and New York-Presbyterian Hospital (NYP), a non-profit health system, both identified increasing food needs at the start of the pandemic and developed innovative solutions. The Health Collaborative found that patients’ needs for food and transportation often coexisted, and they shared data with their local transportation agency to identify neighborhoods with high rates of food and transportation needs so they could improve routes. NYP created a food insecurity order in its electronic health record and worked alongside their CSP partners to expand the availability of produce so orders could be fulfilled. In another example, as a result of feedback from multisector collaboration, the Baltimore City Health Department increased the number of mental health resources that are free and tailored for the African-American community.
Bridge organizations engaged their clinical and community partners early and often. Stakeholders were involved in the early stages of planning the interventions and continue to be a key part of bridge organization approaches to building and scaling the AHC Model. Rocky Mountain Health Plans implemented a multifaceted approach to regularly and consistently engage clinical partners around a collective vision for prioritizing and addressing HRSNs across western Colorado. Many bridge organizations plan to maintain their advisory boards beyond the AHC Model and leverage their multisectoral partnerships to identify sustainable funding streams for clinical and community services.
Scale And Spread Of AHC Innovations
As the AHC Model has ended, participating communities are using infrastructure built during the model to scale and spread the tested interventions. Many health care system bridge organizations, such as AMITA Health in Illinois, are working to expand HRSN screening and referral infrastructure to new clinics and patient populations based on best practices ascertained through the model. CMS’ investment in AHC Model communities has also sparked ongoing payer partnerships for awardees.
For example, Allina Health’s AHC work facilitated a new payment model trial with Blue Cross and Blue Shield of Minnesota. This partnership supported the development of Allina Health’s systemwide HRSNs program, through which more than 45,000 screenings have been completed and more than 2,000 patients have opted-in to navigation services since January 2022. The Camden Coalition partnered with NJ Medicaid as a Regional Health Hub and will continue to act as a clinical-community integrator in that role. The partnerships fostered by the model have also supported multisector data integration efforts, such as Dignity Health’s ability to survey partnering community service providers to support implementation of a statewide health information exchange that includes a closed-loop referral system. These efforts continue to grow as the CMS-funded model test winds down.
CMS Continues To Build On AHC
The CMS Innovation Center has shared tools and resources from AHC as broadly as possible. With permission from the authors of the original question sets, the AHC HRSN Screening Tool is now available for public use following the preferred citation and notification process for each screening question. CMS has also posted a resource guide on using the tool and promising practices for implementing screening protocols. The Innovation Center secured panel and question codes for the AHC HRSN Screening Tool through Logical Observation Identifiers Names and Codes. This enables interoperable exchange of data collected using the tool and further aligns it with parts of the United States Core Data for Interoperability, a standardized set of health data classes and data elements for interoperable health information exchange. The AHC Screening Tool is one of the most common tools in the field and has been validated alongside the Your Current Life Questionnaire developed by Kaiser Permanente’s Care Management Institute.
The CMS Innovation Center is building on the work of the AHC Model and its predecessors by incorporating requirements, incentives, or options for HRSN screening, referral, or both for all or part of other models’ populations. Recently, the CMS Innovation Center committed to moving towards a health system that achieves equitable outcomes through high quality, affordable, person-centered care. This strategy includes broadening efforts to incorporate HRSN screening tools and facilitate coordination with social service providers in existing and future model tests.
The new ACO Realizing Equity, Access, and Community Health (REACH) Model specifically builds on lessons from implementing the AHC Model in a few ways. First, REACH ACOs are required to identify underserved communities within their aligned beneficiary populations and implement initiatives to measure and reduce health disparities through required Health Equity Plans; these are similar to the Health Resource Equity Plans required within the AHC Model. Additionally, the ACO REACH Model builds on the AHC Model’s investment in the infrastructure necessary to support whole-person care. That is why, to mitigate historical disincentives, the ACO REACH Model includes a financial benchmark adjustment for participating REACH ACOs serving a disproportionate number of underserved beneficiaries. It also moves REACH ACOs towards collecting and reporting HRSN data on their aligned beneficiaries alongside demographic data critical to supporting Health Equity initiatives.
The AHC Model has also informed CMS’ contribution to a comprehensive federal approach to address social determinants of health and improve social service connections. In Medicare, CMS is drawing from promising practices in the AHC Model to work with provider and payer communities, including Accountable Care Organizations and Medicare Advantage plans to address health-related social needs in the community.
In the 2023 Physician Fee Schedule proposed rule, CMS is proposing to provide advance shared savings payments to new low revenue Shared Savings Program ACOs, inexperienced with performance-based risk Medicare ACO initiatives that serve underserved populations. Under the proposed approach, these ACOs could use the advance investment payments to address Medicare beneficiaries’ social needs. CMS has also finalized a rule requiring special needs Medicare Advantage plans to use health risk assessment tools that include questions about certain social needs (housing stability, food security, and access to transportation); this is similar to social needs included in the AHC Model Health-Related Social Needs Screening Tool.
Additionally, CMS has adopted two quality measures based on the AHC Model for use within the Hospital Inpatient Quality Reporting Program. Both of these measures are also being considered for the APM Performance Pathway reported by Shared Savings Program ACOs, and one of the measures is being considered for the Merit-Based Incentive Payment System Program. Medicaid and CHIP are inherently flexible and have long supported states in addressing social determinants of health including transportation and housing supports. Furthermore, CMS expressed even greater openness to considering section 1115 demonstration waivers, state plan amendments, and managed care contracting to implement payment innovation that improves quality, equity, and whole-person care, including addressing HRSNs.
As the AHC Model ends—and with the release of future evaluation reports—we will continue to share best practices for clinical-community partnerships and the other interventions tested within the model, as well as impacts on health outcomes, utilization, costs, and disparities. CMS is well-positioned to improve the health of the US population and dismantle long-standing inequities by addressing social determinants of health.
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