Next week — May 18, 2016 — is the deadline for bridge organizations to submit their applications to CMS for the Accountable Health Communities (AHC) model. For the past few weeks, Healthify has been reviewing how software can support the goals of Track 1 Awareness and Track 2 Assistance. Today we review Track 3 Alignment — the largest and most complex of the three interventions proposed by CMS. Track 3 is a $4.5 million grant that will be awarded to 20 bridge organizations to answer the following question: Will a combination of community service navigation and partner alignment at the community level improve total health care costs and inpatient and outpatient health care utilization?
Summation of AHC Track 3 Alignment:
Track 3, like Tracks 1 and 2 before it, requires bridge organizations to inventory local community services. The included community services need to align with issues identified in the community needs assessment that is to be administered during the implementation period. Identified needs are stratified into two groups by CMS: "core" and "supplemental." All Medicaid and Medicare beneficiaries will be screened for core needs, like food, housing, violence, and access to transportation; whereas supplemental needs screenings, such as family and social supports, education, income, and health behaviors will be optional assessments.
Unlike Tracks 1 and 2, however, Track 3 does not call for randomizing the intervention for beneficiaries; comparison groups will be used instead, and their interventions will be tracked by CMS. Providers, care coordinators, and community services will track utilization and must demonstrate bidirectional information exchanges between providers and community agencies. Bridge organizations will have to report outcomes related to the number of referrals made, referrals completed, and beneficiaries’ needs resolved.
Referrals to community services will take place with high-risk beneficiaries who self-report two or more emergency room visits in the proceeding 12 months. Like Track 2, Track 3 Alignment will require staff to conduct in-depth assessments, care planning and follow-up meetings, and multiple attempts at resolving identified issues. Since a key aspect of Track 3 is partner alignment at the community level, bridge organizations will be tasked with managing continuous quality improvement to ensure that resource capacity, accurate data, and misalignment between services and needs are shared amongst all participating organizations.
Milestones and Deliverables of AHC Track 3 Alignment:
- Establish relationships between hospitals, health centers, and behavioral service providers to screen either 75,000 Medicaid and Medicare beneficiaries or 51% of all beneficiaries within a geographic region
- Deliver screenings electronically through clinical staff or arranged through a third-party organization
- Update and maintain a database of services every six months
- Submit operating procedures detailing the exchange of data and interventions
- Report data to CMS on screenings, accepted interventions, intervention results, and availability and utilization of local services
- Build and maintain active relationships with community service providers
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.
Care Coordination: Healthify keeps track of beneficiaries’ risk levels, needs assessments, notes, engagement attempts, and referral requests in a patient record so navigators spend less time on consolidating data and more time focusing on required interactions and interventions with beneficiaries. Healthify’s bidirectional flow of data allows providers and community services to close the loop on referrals.
Quality Improvement: Healthify will work with bridge organizations and participating partners to structure the right reporting mechanisms. Healthify can integrate into multiple systems in order to pull all required information. Healthify will be able to help bridge organizations easily report and make improvements to follow-up interventions, caseloads, and referral success rates.
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.