Accountable Health Communities: Track 1 Awareness


Last week, the Healthify Editorial discussed implementing the Accountable Health Communities (AHC) model. The AHC model is premised on finding the answers to three large questions around social determinants. Track 1 Awareness, the model we are examining today, awards $1 million over five years to answer the following question: "Will increasing beneficiary awareness of available community services through information dissemination and referral impact total health care costs, inpatient and outpatient health care utilization, and health and quality of care?"

Summation of AHC Track 1: Awareness 

Bridge organizations that want to answer that question with have to partner and engage with state Medicaid, clinical delivery sites, and community service providers in order to effectively answer that question. Institutions that take Track 1 will have to inventory local community services, screen all Medicare and Medicaid beneficiaries, and make referrals to community service providers through a targeted intervention with beneficiaries. They will be required to periodically report all findings back to CMS regarding beneficiary screenings and the success of the intervention. 

Beneficiaries will be stratified into high- and low-risk categories based on the frequency of emergency department (ED) visits. They are then to be randomly placed in either awareness (i.e. receive social determinants intervention) or comparison groups (i.e. usual care) after they have been screened and health-related social needs are found to be present.  If they have more than two ED visits in under 12 months, then they are randomly placed into a either a high-risk awareness group or a high-risk comparison group. These two groups are the primary focus for evaluation purposes. Those beneficiaries who have fewer than two ED visits with 12 months are to be randomly placed in either a low-risk awareness group or a low-risk comparison group. 

Milestones and Deliverables of AHC Track 1: Awareness

  • Submit memorandum of understanding with clinical sites
  • Share resource inventory with partner organizations
  • Maintain and update the resource directory for partners
  • Screen 37,500 beneficiaries and share data with CMS
  • Provide and review community referral summary with 1,828 beneficiaries (high-risk awareness)
  • Submit ID numbers and data on health-related social needs and coordinate with state Medicaid agency to submit utilization and payment data for beneficiary ID numbers to CMS

How Healthify Supports the AHC Model: 

Resource Inventory: Healthify's Community Resource Platform is a quick and efficient way for bridge organizations to generate, maintain, and share the required community resource inventory with partner organizations. The Community Resource Platform is a searchable database that allows the easy creation of recommended resources for high-risk beneficiaries who are placed in the awareness intervention group. 

Screening: Healthify offers smart, culturally competent, and user-friendly assessments to identify beneficiaries with social health needs. Assessments are easily configurable and automatically generate tailored referral summaries. Your organization will be able to screen 37,500 beneficiaries either at point-of-care or remotely. Healthify's data indicates that assessments completed in a care context have a 95% completion rate versus 28% for remotely administered assessments.

Data Reporting: A key component of the AHC is data reporting. Healthify's analytics platform makes it easy for bridge organizations and their partners to gather required information in one platform and submit their results back to CMS in order to comply with the model's data submission requirement. 

Topics: social determinants of health Medicaid

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