32 healthcare organizations to pilot test new CMS community health model

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The 32 participants named this week will take part in two of three tracks, focusing on assistance and alignment.

Yale New Haven Hospital and Hackensack University are among the 32 organizations that will test a new Medicare and Medicaid model beginning in May that aims to bridge the gap between clinical and community providers.

The Centers for Medicare & Medicaid Services announced Thursday it selected 32 participants that will serve as local hubs that link clinical and community services and address such social needs as housing instability, food insecurity, utility needs, interpersonal violence and transportation.

The agency intends to test the three-track Accountable Health Communities Model over a five-year period. The 32 participants named this week will take part in two of the tracks that focus on assistance and alignment. The goal of the program is to reduce healthcare costs and avoidable healthcare use at the same time it improves health and quality of care of Medicare and Medicaid beneficiaries.

Organizations in the assistance track will each receive up to $2.57 million to provide person-centered community service navigation services to assist high-risk patients with accessing needed services. Those in the alignment track will each receive as much as $4.5 million to provide navigation services and also work to ensure that the necessarily services and supports are available and responsive to the needs of patients.

As examples of how the assistance track model may work, CMS said that one of the participants, Community Health Network Foundation in Indianapolis, will partner with the Eastside Redevelopment Committee, an organization that represents 50 businesses and community-based organizations focused on improving health through high-quality support services, educational programs and workforce development. The organizations will work together to serve residents of East Indianapolis, a community where 40% of the population received Indiana Medicaid services in 2015 and an emergency room utilization rate above the national average.

Oregon Health & Science University (OHSU) will participate in the alignment track and work with more than 50 clinical sites, community service providers and local health departments to reduce healthcare utilization and costs to more than 300,000 beneficiaries across nine rural counties in Oregon. OHSU plans to coordinate the activities through the Oregon Rural Practice-based Research Network, a statewide network of primary care clinicians, community partners, and academicians dedicated to studying the delivery of healthcare to rural residents and to reducing rural health disparities.

“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 Patrick Conway, M.D., deputy administrator for innovation & quality at CMS, in the announcement. “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 third track of the model, the awareness track, is aimed to increase beneficiary awareness of available community services through information dissemination and referral. CMS said it will make announcements about that track this summer. Participants in the awareness track will receive up to $1 million.

Here is the full list of participants:

Assistance track

Alexian Brothers Network, Arlington Heights, Illinois

Allina Health System, Minneapolis

CHRISTUS Santa Rosa, San Antonio, Texas

Community Health Network Foundation, Indianapolis

Hackensack University, New Jersey

Mountain States Health Alliance, Johnson City, Tennessee

Nevada Primary Care in Carson City

Partners in Health Inc, Charleston, West Virginia

St. Joseph’s Hospital Health Center, Syracuse, New York

Tift County Hospital Authority in Georgia

UT Health Sciences Ctr, Houston

Yale-New Haven Hospital in Connecticut

Alignment Track

Baltimore City Health Department, Maryland

Camden Coalition of Healthcare Providers, New Jersey

Care New England Health System, Providence, Rhode Island

Danbury Hospital in Connecticut

Delta Health Alliance Inc., Leland, Mississippi

Denver Regional Council of Governments in Colorado

Dignity Health dba St. Joseph's Hospital & Medical, Phoenix

Health Net of West Michigan

MyHealth Access Network, Inc., Tulsa, Oklahoma

Oregon Health & Science

Parkland Center for Clinical Innovation, Dallas

Presbyterian Healthcare Services, Albuquerque, New Mexico

Reading Hospital, Pennsylvania

Rocky Mountain HMO, Grand Junction, Colorado

The Health Collaborative, Cincinnati

NewYork-Presbyterian Hospital

United Healthcare Services inc., Minnetonka, Minnesota

United Way of Greater Cleveland

University of Kentucky Research Foundation

VHQC dba Health Quality Innovators, Richmond, Virginia