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www.hcgc.org
January 29, 2016
Accountable Health Communities ModelExploring the Greater Columbus Region’s readiness to pursue a
CMS funding opportunity.
www.hcgc.org
Webinar Objectives
• Explore which track appears to be a good fit for Greater Columbus and what would best align with work taking place in the region.
• Explore the readiness of medical neighborhood partners to pursue CMS funding and, if funded, participate in an AHC project.
• What organization is best suited to serve as the bridge organization in Greater Columbus?
www.hcgc.org
Today’s Agenda
• Review the AHC Model Overview
• Explore the Three Funding Tracks
• Explore the Roles of AHC Model Participants
• Participant Discussion and Feedback
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Model Background
The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care.
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Model Background
Bridge Organization
Evaluation
Referral Infrastructure
Screening Tools
Care Coordination
Fiscal Role
Providers -1 PCP
-1 Hospital -1 Behavioral Health
State Medicaid Agency
Social Service Agencies
What will it take to advance AHC in Greater Columbus?
www.hcgc.org
Key Dates
• LOI Due (Optional & Non-Binding): February 8, 2016
• Proposal Due: March 31, 2016
• Grant Awarded: November 1, 2016
• Grant Period: January 1, 2017 – December 31, 2021
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Key Definitions
• Community-Dwelling Beneficiary = Medicare or Medicaid beneficiary, regardless of age, who is not residing in a correctional facility or long-term care institution when accessing care at a participating clinical delivery site. Includes Medicaid and Medicare advantage plans.
• Health-Related Social Need = refers to community services need that can be linked to health care, including the cost of care and inpatient and outpatient utilization of care.
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Health-Related Social Needs
Core Needs (Required)Housing InstabilityUtility NeedsFood InsecurityInterpersonal ViolenceTransportation
Supplemental NeedsFamily & Social SupportsEducationEmployment & IncomeHealth BehaviorsOthers
Grantees will be required to screen beneficiaries for all of the core health-related social needs.
Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.
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What does the model fund?
Over a five-year performance period, CMS will implement and test a three-track model:
• 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 beneficiaries
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Funding Opportunities
• Track 1 - Awareness (12 Awards) • Up to $1 million over 5 year test period
• Track 2 - Assistance (12 Awards)• Up to $2.57 million over 5 year test period
• Track 3 - Alignment (20 Awards)• Up to $4.51 million over 5 year test period
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Exploring the Funding Tracks
Track 1 - Awareness
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Exploring the Funding Tracks
Beneficiary Selection Process
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Exploring the Funding Tracks
Track 2 - Assistance
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Exploring the Funding Tracks
Track 3 - Alignment
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Partner Roles
Bridge Organization
• Partner w/ a State Medicaid Agency
• Partner w/ clinical providers to provide required AHC interventions and implement a CMS screening tool
• Develop and maintain a database of community services. Updated every 6 months.
• Manage grant funding
• Lead the grant application process
• Track 2 & 3 – Coordinate community service navigation
• Track 3 - Partner w/ community service providers to align quality improvement
www.hcgc.org
Partner Roles
State Medicaid Agency
• MOU w/ Bridge Organization
• Data collection and reporting
• Sustainability planning
• Annual Intervention review to ensure services are not duplicative
• Annual review of the AHC intervention and a letter of support
• Track 3 – Participate on Advisory Board
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Partner Roles
Clinical Providers
• At least 1 primary care provider, 1 hospital system, 1 behavioral health provider
• MOU w/ Bridge Organization
• Screen at least 75,000 Medicaid/Medicare beneficiaries per year for health-related social needs. Screening tool provided by CMS
• Track 3 Only – Reach at least 51% of Medicaid and Medicare beneficiaries served by participating providers in the geographic region (geographic region defined by applicant)
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Partner Roles
Community Service Providers
• MOU w/ Bridge Organization
• Track 1 & 2 – Receive referrals from clinical providers
• Track 3 – Receive referrals and actively participate in service alignment on quality improvement
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Model Background
Bridge Organization
Evaluation
Referral Infrastructure
Screening Tools
Care Coordination
Fiscal Role
Providers -1 PCP
-1 Hospital -1 Behavioral Health
State Medicaid Agency
Social Service Agencies
What will it take to advance AHC in Greater Columbus?
www.hcgc.org
Accountable Health Communities
Questions
www.hcgc.org
Webinar Objectives
• Explore which track appears to be a good fit for Greater Columbus and what would best align with work taking place in the region.
• Explore the readiness of medical neighborhood partners to pursue CMS funding and, if funded, participate in an AHC project.
• What organization is best suited to serve as the bridge organization in Greater Columbus?
www.hcgc.org
Exploring the AHC Model
Exploratory Question #1
• From your unique perspective, should the Greater Columbus region pursue the AHC Model grant collaboratively?
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Exploring the AHC Model
Exploratory Question #2
• What track aligns with work taking place in the Greater Columbus region?
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Exploring the AHC Model
Exploratory Question #3
• What organization in the community is best-suited to serve as the bridge organization?
www.hcgc.org
Partner Roles
Bridge Organization
• Partner w/ a State Medicaid Agency
• Partner w/ clinical providers to provide required AHC interventions and implement a CMS screening tool
• Develop and maintain a database of community services. Updated every 6 months.
• Manage grant funding
• Lead the grant application process
• Track 2 & 3 – Coordinate community service navigation
• Track 3 - Partner w/ community service providers to align quality improvement
www.hcgc.org
Next Steps
If you are interested in learning more, please contact Michelle Missler ([email protected])
or John Leite ([email protected]).
Funding Opportunity Page: https://innovation.cms.gov/initiatives/AHCM
