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Centers for Medicare & Medicaid Services: Accountable Health Communities Model

Deadline: March 31, 2016

The Accountable Health Communities Model is based on emerging evidence that addressing health-related socials needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.

This model will promote clinical-community collaboration through:

  • Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs
  • Referral of community-dwelling beneficiaries to increase awareness of community services
  • Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services
  • Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries

Over a five-year period, CMS will implement and test a three-track model based on promising service delivery approaches. Each track features interventions of varying intensity that link beneficiaries with community services:

  • Track 1 Awareness – Increase beneficiary awareness of available community services through information dissemination and referral
  • Track 2 Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services
  • Track 3 Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries

Applicants may apply to participate in one or two tracks, but successful applicants will be selected to participate in a single track only.

Each of the tracks requires the award recipient to serve as a hub responsible for coordinating efforts to:

  • Identify and partner with clinical delivery sites (CDS) (e.g., clinics, hospitals)
  • Conduct systematic health-related social needs screenings and make referrals for all eligible Medicare and Medicaid beneficiaries
  • Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs and who are randomized to the intervention group to community service providers that might be able to address those needs
  • Align model partners to optimize community capacity to address health-related social needs (Track 3 only)

Amount: Funding varies by track:

  • Track 1 Awareness: Approximately $12,000,000, for up to 12 awards of up to $1,000,000 each
  • Track 2 Assistance: Approximately $30,840,000, for up to 12 awards of up to $2,570,000 each
  • Track 3 Alignment: Approximately $90,200,000, for up to 20 awards of up to 4,510,000 each

Eligibility: 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.

Link: https://innovation.cms.gov/initiatives/ahcm/

Notes: Submit a non-binding Letter of Intent by February 8, 2016 at http://innovationgov.force.com/ahcExternal Link Policy

CMS will host two webinars about the opportunity on January 21 and January 27, 2016. Register here: https://innovation.cms.gov/resources/ahcm-appreqs.html

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