CMMI’s Accountable Health Communities Social Screening ...CMMI’s Accountable Health Communities...

The Social Interventions Research and Evaluation Network (SIREN)

CMMI’s Accountable Health Communities Social Screening Tool Webinar9.25.17

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Onlineresourcehub

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SearchableEvidenceLibrary

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ConsultationandCollaborationOpportunities

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Today’sSpeakers

KatherineVerlander,MPHDivisionofPopulationHealthIncentives&Infrastructure

CMSCMMI

AlexBillioux,MD,DPhilDivisionofPopulationHealthIncentives&Infrastructure

CMSCMMI

AccountableHealthCommunities

CMSHealth-RelatedSocialNeeds(HRSN)ScreeningTool

PresentersAlexanderBillioux,MD,DPhilKatherineR.Verlander,MPH

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AccountableHealthCommunitiesModelOverview&Structure

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• Manyofthelargestdriversofhealthcarecostsfalloutsidetheclinicalcareenvironment.

• Socialandeconomicdeterminants,healthbehaviorsandthephysicalenvironmentsignificantlydriveutilizationandcosts.

• Thereisemergingevidencethataddressinghealth-relatedsocialneedsthroughenhancedclinical-communitylinkagescanimprovehealthoutcomesandimpactcosts.

• TheAHCmodelseekstoaddresscurrentgapsbetweenhealthcaredeliveryandcommunityservices.

WhytheAccountableHealthCommunitiesModel?

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TheAccountableHealthCommunitiesModelisa5-yearmodelthattestswhethersystematicallyidentifyingandaddressingthehealth-relatedsocialneedsofcommunity-dwellingMedicareandMedicaidbeneficiariesimpactstotalhealthcarecostsandutilization.

WhatDoestheAccountableHealthCommunitiesModelTest?

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Health-RelatedSocialNeeds

CoreNeeds *Supplemental NeedsHousingInstability

UtilityNeeds

FoodInsecurity

InterpersonalViolence

Transportation

Family&SocialSupports

Education

Employment&Income

HealthBehaviors

* This list is not inclusive11

AccountableHealthCommunitiesModelStructure

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• 32communitiesacross24States• 6intheNortheast• 7intheMidwest• 11intheSouth• 8intheWest• Urbanandrural

OverviewofBridgeOrganizationsinAssistance&AlignmentTracks

AHCBridgeOrganizations

AssistanceTrack StateAlexian BrothersNetwork Illinois

AllinaHealthSystem Minnesota

CHRISTUSSantaRosa Texas

CommunityHealthNetworkFoundation

Indiana

HackensackUniversity NewJersey

MountainStatesHealthAlliance Virginia

NevadaPrimaryCare Nevada

PartnersinHealth,Inc. WestVirginia

St.JosephsHosp.HealthCtr. NewYork

TiftCountyHosp.Authority Georgia

UTHealthSciencesCenter Texas

Yale-NewHavenHospital Connecticut

AlignmentTrack StateBaltimoreCityHealthDepartment MarylandCamdenCoalitionofHealthcareProviders NewJerseyCareNewEnglandHealthSystem RhodeIslandDanburyHospital ConnecticutDeltaHealthAlliance,Inc. MississippiDenverRegionalCouncilofGovernments ColoradoDignityHealthdba St.Joseph'sHospital&Medical

Arizona

HealthNetofWestMichigan MichiganMyHealth AccessNetwork,Inc. OklahomaOregonHealth&ScienceUniversity OregonParklandCenterforClinicalInnovation TexasPresbyterianHealthcareServices NewMexicoReadingHospital PennsylvaniaRockyMountainHMO ColoradoTheHealthCollaborative OhioTheNewYorkandPresbyterianHospital NewYorkUnitedHealthcareServiceInc. HawaiiUnitedWayofGreaterCleveland OhioUniversityofKentuckyResearchFoundation KentuckyVHQCdba HealthQualityInnovators Virginia

AssistanceTrack AlignmentTrackStart-Up PeriodMay2017-January2018• Finalizingrelationshipswithclinical

deliverysites• DevelopingSOPsforscreening, referral,

randomization,andnavigation• Hiringandtrainingstaff

Start-Up PeriodMay2017- April2018• Finalizingrelationshipswithclinical

deliverysites• DevelopingSOPsforscreening,referral,

andnavigation• Hiringandtrainingstaff• EstablishingAdvisoryBoard

ImplementationPeriodFebruary 2018-April2022• Offeringuniversalscreeningtobeneficiaries

atparticipatingsites• Providingcommunityreferralsand

navigationservicestothoseeligible

ImplementationPeriodMay2018- April 2022• Offeringuniversalscreeningtobeneficiaries

atparticipatingsites• Providingcommunityreferralsand

navigationservicestothoseeligible

AHCModelTimeline

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Bridgeorganizationswill:• Screeninatleastoneofeachofthefollowingtypesofclinicaldeliverysites:a

hospital(includingtheEmergencyDepartmentandLaborandDeliveryunit);aprimarycareproviderorpractice;andaproviderofbehavioralhealthservices.

• UsethescreeningquestionsprovidedbyCMStoscreenforcorehealth-relatedsocialneeds

• Chooseanappropriatemethodtoadministerthescreeningtool

• Systematicallysubmitallinformation,includingbeneficiaryidentifiers,receivedthroughthisscreeningtooltoCMSoritscontractors

• Makethetoolavailabletoallbeneficiariesregardlessoflanguage,literacylevel,ordisabilitystatus

AHCHRSNScreening

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Process1. Background research2. Meetings with Technical Expert Panel3. CMS finalization and permissions

Guidingprinciplesfortooldevelopment:*1. Consistentlyidentifybroadsetofneeds2. Short,accessible,consistent,andinclusive3. Evidence-basedandpracticallyinformed

CMSHRSNScreeningToolDevelopment

18* Billioux, A., K. Verlander, S. Anthony, and D. Alley. 2017. Standardized screening for health-related social needs in clinical settings: The accountable health communities screening tool. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/wp-content/uploads/2017/05/ Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf .

CMSHRSNScreeningTool

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CMSHRSNScreeningTool

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CMSHRSNScreeningTool

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CMSHRSNScreeningTool

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CMSHRSNScreeningTool

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CMSiscurrentlyclearingquestionsrecommendedbytheTEPforthefollowingsupplementalsocialneeddomains:• FinancialStrain• Employment• Education• FamilyandCommunitySupport• PhysicalActivity• SubstanceUse• MentalHealth• Disabilities

CMSHRSNScreeningTool

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• AssistanceTrackwillbeginimplementingthetoolinFebruary2018

• AlignmentTrackwillbeginimplementinginMay2018

• CMSwillmonitortheuseofthetoolandsolicitfeedbackfromAHCawardrecipients

• CMSwillweighevaluationimpactswhenconsideringanymodificationstothetool

NextStepsfortheTool

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For importantupdatesandmoreinformationontheAccountableHealthCommunitiesModelvisit:

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

ImportantAccountableHealthCommunityModelWebLinks

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