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CMS Picks Care Coordination Hubs for Accountable Health Program

The Accountable Health Communities program will focus on enhancing care coordination and public health partnerships to address socioeconomic determinates of health.

Socioeconomic determinates of health and care coordination

Source: Thinkstock

By Jennifer Bresnick

- CMS has selected 32 participants for its Accountable Health Communities (AHC) program, an effort to improve care coordination and address the socioeconomic determinates of health for vulnerable Medicare and Medicaid populations.

The five-year initiative, first announced in January of 2016, offers $157 million in grant funding to encourage community healthcare providers to engage in population health management strategies to address many of the underlying social factors of poor health and chronic disease, including barriers to care access, poverty, low health literacy, and poor lifestyle choices.

“We know that innovation at the state and community level is essential to improve health outcomes and lower costs. In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country,” said Dr. Patrick Conway, CMS Deputy Administrator for Innovation & Quality.

“As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries, and their families and caregivers.”

The AHC program includes three different tracks that will allow participants to scale up their population health and care coordination competencies while establishing new partnerships with community wellness providers. 

The first track enhances patients’ awareness of available community health services, while the second and third components of the program focus on actively connecting patients with tools to address their socioeconomic health-related needs and building provider partnerships across the community to develop a robust network of partnerships to respond to the full range of patient issues.

The 32 organizations unveiled in this announcement will take part in the two higher-level pieces of the initiative, known as the Assistance and Alignment tracks.  They hail from more than a dozen states across the country, including Texas, New Jersey, Pennsylvania, Kentucky, and Virginia.

In Indianapolis, Indiana, where 40 percent of residents receive Medicaid assistance, the Community Health Network Foundation will work with the Eastside Redevelopment Committee to improve patient education and workforce development.  

As part of the Assistance track, the organizations hope to reduce costs and reinforce the community’s abilities to access quality care for high-risk individuals.

Oregon Health & Science University will take part in the Alignment track, CMS says, by working with over 50 sites in nine counties to reduce health disparities for Medicare and Medicaid beneficiaries.

CMS hopes that enrolling a diverse group of healthcare organizations for the program will help to provide insight into how to manage the health of populations with significant socioeconomic needs. 

Providers, health IT developers, and policymakers have started to make a concerted effort to understand how social determinates of health impact population wellness trends – and how to use those insights to reduce costs, streamline workflows, and deliver more preventive, proactive patient care.

As the financial pressures of value-based reimbursement drive providers towards developing more coordinated and personalized care for individuals, new partnerships with community and public health stakeholders are expanding the role of the traditional healthcare system.

“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 former HHS Secretary Sylvia M. Burwell when announcing the AHC initiative.

“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.”

CMS will conduct independent evaluations of the effectiveness of the AHC participants to determine how the population health management project impacts cost savings and service utilization.  

Organizations participating in the Alignment and Assistance tracks will start working on their AHC care coordination and community involvement strategies in May of 2017. 


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