CMS's Accountable Health Communities to Focus on Unmet Social Needs
Last week, the Center for Medicare and Medicaid Innovation announced its first program focused on addressing a patient’s social needs. This 5-year, $157 million pilot program, called Accountable Health Communities, will try to bridge the gap between clinical and social services, testing whether addressing these needs can improve health, lower costs, and improve quality for Medicare and Medicaid beneficiaries.
Why addressing social needs is necessary to improve health and reduce disparities
Unmet social needs can put people at increased risk for developing chronic conditions and affect their ability to effectively manage those conditions. For example, food insecurity can make it difficult for someone with diabetes to eat healthy and manage his or her diabetes, and poor quality housing can contain indoor air pollutants and other asthma triggers. There are already many examples of smaller programs helping with meeting social needs, including the use of community health workers/promotores or “hotspotting.” (In Latino communities, community health workers are known as promotores—trusted members of the communities they serve who are trained to offer health and supportive services.)
Addressing unmet social needs can also help to address persistent health disparities. Vulnerable groups—including racial and ethnic minorities, people who are low-income, and people living in underserved areas—are more likely to have serious chronic conditions and to face additional barriers to getting access to or managing their care, such as a lack of transportation.
The Accountable Health Communities model will test how different interventions will affect total health care costs, health care utilization, quality of care, and health of Medicare and Medicaid beneficiaries. The program will address at least the following core areas:
- Housing instability and quality
- Food insecurity
- Utility needs
- Interpersonal violence
- Transportation needs
How Accountable Health Communities will address social needs
CMMI will award funds to 44 different organizations, with funding for each site ranging from $1 million to $4.5 million. Eligible organizations include community-based organizations, health care provider practices, hospitals and health systems, institutions of higher education, local government entities, and tribal organizations. Funding through this program cannot pay for any of the community services.
For example, funding cannot be used to pay for food or transportation. Instead, this model aims to address these health-related social needs through:
- Screening to identify unmet needs
- Making referrals to increase awareness of community services
- Providing high-risk patients with navigation assistance in getting access to community services
- Encouraging alignment between clinical and community services
As the health care system moves toward rewarding providers for keeping patients healthy, it is vital to address unmet social needs and to create strong linkages between clinical care and social services. The results from this program could go a long way in our understanding of how to create these linkages to reduce costs, improve health, and reduce disparities.