Accountable Health Communities Model

The Accountable Health Communities Model (AHCM) is an opportunity to test, over five years, if systemically identifying and attempting to address the health-related social needs (housing, food, utilities, safety, transportation) through referral and community navigation can reduce healthcare costs, inpatient and outpatient utilization, and improve healthcare quality and delivery. This PowerPoint presentation provides a brief overview of the project.

Western Colorado was selected as one of thirty two sites across the country to participate in this Center for Medicare and Medicaid Innovation initiative from May 1, 2017 to April 30, 2022.

Role of Rocky Mountain Health Plans (RMHP) in the AHCM

Provide Administrative Infrastructure and Support

RMHP is participating in the AHCM because it is in strategic alignment with goals such as coordinating assessment and care planning, addressing the needs of the whole person, and investing in technology and data sharing. It is also in alignment with Colorado Medicaid’s expectations for the Regional Accountable Entity (RAE). AHCM presents an opportunity to accelerate coordination across medical, behavioral and social service providers and better address the social needs of our community members. In addition, this is a meaningful opportunity to provide policy direction and feedback to federal and state policy leaders and to move the entire healthcare system in a positive direction.

RMHP is committed to participating in this opportunity only to the extent that it has a positive impact on the community.

Role of Practices in the AHCM

• Administer the AHCM social needs screening: Beginning in 2018, participating practices, with the support of Rocky, will administer a social needs screening to most Medicare and Medicaid enrollees.
  • AHCM Social Needs Screener in English
  • AHCM Social Needs Screener in Spanish
• Access to a Community Resource Inventory for Referrals: Practices who participate will receive access to a community resource inventory that can generate referrals to assist clients with their identified social needs.
• Access to Community-Based Navigation Support for High Needs Patients: Patients with high needs (who have had more than two ER visits in the last year) will have access to community-based navigation support.

Role of Community Based Organizations (CBOs) in the AHCM

• Receive Referrals: Many Community Based Organizations already provide services to individuals who meet the navigation criteria (>2 ER visits & 1 social need). Better coordination and collaboration between clinical and non-clinical providers may result in improvements in services for these clients.
• Track Data: CMS wants to capture the outcome and the costs of the Community Based Organizations interventions
• Participate in the Advisory Committee: In the Advisory Committee, Community Based Organizations will have an opportunity to partner with clinical/medical settings to identify gaps in the community service continuum, prioritize community needs and develop a plan to address some of those community needs.

We recognize and thank the Community Partners that have signed an MOU to-date.

The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

The project described was supported by Funding Opportunity Number 1P1CMS331575-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.