Allina Health has been chosen by the federal Centers for Medicare & Medicaid Services to participate in a five year Accountable Health Communities (AHC) model test to see if bridging the gap between clinical and community service providers for Medicare and Medicaid patients with health-related social needs can improve the health of patients and reduce the cost of care. Health-related social needs include housing instability, food insecurity, utility needs, interpersonal violence and transportation. Allina Health is one of just 32 organization nationwide selected to participate in the project.
By addressing critical drivers of poor health and high health care costs, the AHC model aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries. Allina Health's target area for this project includes Anoka, Dakota, Isanti, Ramsey and Washington Counties.
"Our role is to screen the Medicare and Medicaid patients we see in our hospitals, primary care clinics, and urgent care centers in the five county target area, to determine health-related social needs, and then help people connect to community resources to address their needs," said Ellie Zuehlke, Allina Health Director of Community Benefit and Engagement. "We know that health-related social needs are critical drivers of unnecessary health care utilization and costs, but are often difficult to address. Our goal is to provide the link between our patients and the community services that can help them before they end up in a hospital emergency room."
"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."
AHC Model Background
The foundation of the Accountable Health Communities Model is universal, comprehensive screening for health-related social needs of community-dwelling Medicare and Medicaid beneficiaries accessing health care at participating clinical delivery sites. The model will test whether systematically identifying and addressing beneficiaries’ health-related social needs impacts total health care costs and reduces inpatient and outpatient utilization. In order to accomplish this, the Assistance and Alignment Tracks will implement and test separate service delivery approaches:
- Assistance Track: Provide community service navigation services to assist high-risk beneficiaries with accessing services to address identified health-related social needs
- Alignment Track: Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries
Allina Health is participating in the Assistance Track. To implement each approach, bridge organizations will serve as ‘hubs’ in their communities, forming and coordinating consortia that will:
- Identify and partner with clinical delivery sites (e.g., physician practices, behavioral health providers, clinics, hospitals) to conduct systematic health-related social needs screenings of all community-dwelling beneficiaries and make referrals to community services that may be able to address the identified health-related social needs;
- Coordinate and connect high-risk community-dwelling beneficiaries to community service providers through community service navigation; and
- Align model partners to optimize community capacity to address health-related social needs (Alignment Track only).