5 years later: 5 lessons from CMS' Accountable Health Communities Model

First launched in 2017, CMS' Accountable Health Communities Model has provided valuable insights on how to better incorporate social determinants screenings and community services navigation and referrals throughout the healthcare system, according to an article posted Aug. 8 in Health Affairs.

The 28 participating organizations included community-based organizations, payers, health information exchanges, hospitals and integrated health systems across 21 states to test whether screening for and addressing social determinants would affect care costs and reduce utilization.

Five key lessons:

1. All participating organizations used a tool to screen Medicare and Medicaid enrollees for social determinants like food insecurity and housing instability. As of June, more than 1.1 million unique screenings have taken place. Over 35 percent of enrollees had at least one health-related social need and were eligible for referral services.
   
   
2. The model included monthly outreach and care correction planning for those with at least one health-related social need and two emergency room visits in the last year. As of June, 137,000 patients accepted support and 92,000 health-related social needs were resolved. Participating organizations said outreach challenges included the need for more staff to do it, more training and difficulty tracking outcomes.
   
   
3. Bridge organizations were key to the model's success by encouraging collaboration between payers/providers and community service providers. As the model ends, many bridge organizations will keep advisory boards so they can continue to find ways to pay for clinical and community services.
   
   
4. The infrastructure built under the model is now being scaled by participating organizations. For example, Chicago-based Amita Health is expanding social determinants screening to new facilities, and Minneapolis-based Allina Health has entered a value-based payment model with Blue Cross and Blue Shield of Minnesota. 
   
   
5. CMS is making the model's tools more accessible by publicly sharing the social determinants screening program and using the model's success to influence parts of the new ACO REACH Model. The ACO model is also influencing new quality measures and Medicare payments and social determinants policy.