What happens after a patient leaves the doctor's office is just as important, if not more so, as what takes place during the visit itself. But bridging that gap between the clinic and community is a major challenge for healthcare and community providers alike.
In an effort to close the divide, the CMS Innovation Center said Thursday it will give up to $120 million to 32 organizations selected to participate in its Accountable Health Communities model. Over five years, the groups will serve as test hubs helping Medicare and Medicaid beneficiaries with health-related social needs including housing instability, food insecurity, domestic violence and transportation.
The three-track model aims to reduce unnecessary healthcare utilization in order to drive down spending, while also improving outcomes and quality of care for patients. Model participants will work to improve community-clinical collaboration by screening beneficiaries for unmet social needs, referring them to the right services or helping them navigate and access those services. They also work to ensure that community services are available and responsive to beneficiaries.
The organizations named Thursday will participate in the assistance and alignment tracks of the Accountable Health Communities model. The 12 organizations in the assistance track will help high-risk beneficiaries navigate community services, and the 20 in the alignment track will do the same while also encouraging alignment among partners to make community services available.
The CMS announcement did not disclose the exact amounts awarded to each grantee. According to a CMS fact sheet, the agency planned to award up to $2.57 million each to the 12 organizations in the assistance track and up to $4.51 million each to the 20 organizations in the alignment track.
The funded organizations included recognized industry names, such as Hackensack University in New Jersey, Yale-New Haven Hospital in Connecticut, and the Oregon Health & Science University, as well as government entities like the Baltimore City Health Department, and associations like the Denver Regional Council of Governments.
The CMS plans to make announcements regarding the remaining track, awareness this summer. It anticipates 12 recipients will participate in that program and receive up to $1 million each.