Accountable Health Communities: Track 2 Assistance


With the grant deadline for the CMS Accountable Health Communities (AHC) model just a couple of weeks away, Healthify is continuing its review of all three tracks of the AHC model. Today we take a look at Track 2 Assistance — a $2.5 million dollar grant over five years — that will allow 12 bridge organizations to answer the following question raised by CMS: “Will providing community service navigation to assist high-risk beneficiaries with accessing community services to address identified health-related social needs impact their total health care costs, inpatient and outpatient health care utilization, and health and quality of care?”

Read: Healthify’s Analysis of Track 1 Awareness

Summation of AHC Track 2 Assistance:

Much like Track 1 Awareness, bridge organizations seeking funds under Track 2 Assistance will have to collaborate with state Medicaid, healthcare providers, and community organizations to make an inventory of all local services that would potentially be useful in addressing the needs of Medicaid and Medicare beneficiaries. AHC awardees will then have to screen beneficiaries for needs and make referrals to the identified community service providers. From that basis, Track 2 begins to diverge from Track 1 with a greater focus on assisting beneficiaries in navigating needs and services and promoting greater patient follow up.

Institutions pursuing Track 2 will have to implement a tool to assist patient navigators in screening beneficiaries for needs and then following up with them to conduct a personal interview at a clinical delivery site no later than two days following the initial needs screening. Case managers then work to develop an action plan that includes a beneficiary’s personal goals and service preferences based of the initial screening and the follow-up interview. The action plan is a step-by-step guide to overcome a beneficiary’s needs that is then shared with all stakeholders in the bridge organizations for a patient-centric approach.

Once a beneficiary accepts the action plan under Track 2, bridge organization case managers and patient navigators begin following up over the next two weeks through text messages, home visits, and scheduling appointments with community service providers. Interventions are repeated monthly until the beneficiary’s needs are resolved. If no resolution is possible, then it has to be categorized as such under two reasons: 1) the service was unavailable; and 2) three attempts were made but with no response or resolution from the beneficiary. 

Every interaction between the navigator and the beneficiary is logged and reported back to CMS. Similar to Track 1, Medicaid and Medicare beneficiaries identified in Track 2 are stratified based on the health screening and then risk-stratified into high and low categories based on the number of ED visits they had in the previous 12 months. High-risk beneficiaries will be randomly placed in either an intervention group or in a comparison group. Those who are placed in the intervention group will receive community referral summaries and community service navigation.

Milestones and Deliverables of AHC Track 2 Assistance:

  • Submit memorandum of understanding with participating sites
  • Share resource inventory with partner organizations
  • Maintain and update the resource directory for partners
  • Screen beneficiaries and stratify based on risk
  • Schedule personal interviews
  • 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 and Personal Interview: Healthify employs a user-friendly screening tool that clinical delivery sites can utilize to assess patients. Its translation API allows for assessments to be translated to over 90 languages, helping with cultural competency. Navigators can use Healthify to remind beneficiaries of the follow-up personal interview and action plan. All plans can be documented in our system to track progress on addressing unmet social needs.

Follow-up Management: Healthify has engagement features that can be tailored to follow up with beneficiaries. Texting and electronic forms of communication work well with Healthify. There is no magic bullet for follow up, however, so Healthify supports traditional methods of follow up like telephone calls and physical action plan print-outs as well.

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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