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Population Health News

CMS Offers $157M to Fund Community Population Health Management

"Keeping people healthy is about more than what happens inside a doctor’s office. Connecting them to local community resources like housing and transportation will ultimately improve their health and reduce the cost to taxpayers."

- Recognizing the need to integrate the social and community needs of patients into population health management on a broader scale, CMS has announced a new $157 million funding opportunity to bolster innovative strategies for helping to address social issues such as housing and food instability, lack of access to transportation, and interpersonal violence.

Population health management and community care

The new five-year Accountable Health Communities Model, advanced by the CMS Innovation Center, will encourage providers to take a more holistic view of population health management as value-based reimbursements and accountable care payment models push healthcare organizations to break down socioeconomic barriers to better health.

“We recognize that keeping people healthy is about more than what happens inside a doctor’s office, and that’s why, for the first time, we are testing whether screening patients for health-related social needs and connecting them to local community resources like housing and transportation to the doctor will ultimately improve their health and reduce the cost to taxpayers,” said HHS Secretary Sylvia M. Burwell.

“The Accountable Health Communities model is yet another step towards building a health care system that results in healthier people and stronger communities and spends our health care dollars more wisely.”

The program will fund up to 44 “bridge communities” that will utilize a standardized needs assessment screening framework for social needs among Medicare and Medicaid beneficiaries. 

Over its lifespan, the initiative will take a three-pronged approach to linking patients with community services and other resources:

Track 1: Increase beneficiary awareness of community services that may be available to address basic instabilities.  Providers will work to make educational materials more available and refer patients to appropriate services when necessary.

Track 2: Provide robust navigation services to actively assist high-risk patients through the process of connecting with community partners and meeting their social needs. 

Track 3: Developing stronger partnerships between healthcare providers and community service providers to increase alignment between clinical and social care.  Participating organizations will take the lead to ensure that community partners are responsive and available to those in need.

As grant recipients work through the three program objectives, they will be become care coordination hubs for their patients, a CMS fact sheet says.  Providers will be responsible for identifying and partnering with appropriate clinical deliver sites and community resources, and will also undertake the task of conducting “systematic health-related social needs screenings” while ensuring that patients who flag positive for high-risk conditions receive the help they need.

“For decades, we’ve known that social needs profoundly affect health, and this model will help us understand which strategies work to help improve health and spend dollars more wisely,” said Dr. Patrick Conway, CMS Deputy Administrator and Chief Medical Officer.

Innovative care strategies with a strong population health management focus, such as the patient-centered medical home and the accountable care organization, have flourished in recent years even as calls intensify across the industry for heightened integration between social, behavioral, and clinical care.

In March of 2015, the Institute of Medicine (IOM) suggested that behavioral health data and socioeconomic status information should be routinely collected under Stage 3 of the EHR Incentive Programs, and that this data should be better integrated into the daily EHR workflows of providers.

Several months later, the American Academy of Nursing issued a position paper and call to action stating that the socioeconomic circumstances and behavioral health history of patients must be taken into account in the clinical setting.

 “There is strong evidence that social and behavioral factors influence health; however, they may not be addressed in clinical care for shared decision-making,” said American Academy of Nursing CEO Cheryl Sullivan. “It is imperative that all stakeholders in health care collaborate to include this information in electronic records, including EHR vendors, health systems, providers, and funders.”

Recent studies have indicated that a tighter link between clinical care providers and community services may be required to address significant racial and socioeconomic disparities in patient outcomes. 

Patients living in certain low-income areas in California are twice as likely as their better-off peers to require lower limb amputations due to diabetes, one study found, while another pinned lower socioeconomic status to a 7 percent increase in the likelihood to experience a hospital readmission for cardiac disease.

Those patients who receive care coordination and population health management services from their providers are 13 percent more likely than others to follow up with a primary care provider after discharge from the hospital, a JAMA study found in 2014.  These patients are also more likely to report better satisfaction and experience fewer readmissions for the same issue, the researchers added.

CMS’ new initiative hopes to improve outcomes while lowering the cost of care for socioeconomically unstable Medicare and Medicaid patients.  The program will test whether increased alignment between clinical and community care can move the needle on several key metrics, including total cost of care, emergency department use, hospital admissions, and quality indicators.

“Eligible applicants are community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations and for-profit and not-for-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers,” CMS says.

Grant funding will be awarded through a competitive process as renewable one-year cooperative agreements.  Each applicant will focus on one of the program three tracks.

For more information on eligibility and how to apply, please see the CMS funding announcement, which is available here.

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