Healthify Blog

CMS Launches New Model to Test Social Determinants

The Innovation Center at the Centers for Medicare and Medicaid Services (CMS) announced the creation of the Accountable Health Communities Model yesterday. It is the first-ever CMS innovation model to focus on the social determinants of health.

Center for Medicare and Medicaid Services (CMS)

The five-year program, according to the announcement on the Health and Human Services website, will "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." This model is expected to raise Medicaid and Medicare beneficiaries' awareness of community-based services, making it more likely they will access community services to receive assistance in times of need or crisis. 

CMS has made $157 million in funding available to support 44 organizations to serve as bridges between clinical and community services. Bridge organizations will create an "inventory [of] local community agencies and provide referrals to those agencies as needed." This will allow for beneficiaries to be treated for needs across a network of services, making bridge organizations sites that "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." 

CMS will consider the model to be effective if organizations achieve a reduction in "total health care costs, emergency department visits, and impatient hospital readmissions." Over the course of the pilot, bridge organizations will have the opportunity to practice continual improvement, evaluating their own network of community services and encouraging the development of services that meet patient needs. Having the ability to realign services will make it more likely that bridge organizations will be able to reduce overall costs and patient readmissions. 

Healthify is tremendously excited by this opportunity: It is, in part, validation from CMS that our model of assessing patients for needs, categorizing community services, and tracking referrals and coordination with community services is the way forward on addressing social determinants. This pilot holds the promise of truly and effectively reducing costs, reducing readmission rates, and improving outcomes. As parties seek to participate in the Accountable Health Communities Model, Healthify looks forward to providing the technology that will make improving CMS beneficiaries' social health possible.

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Topics: social determinants of health Medicaid public health