Kathryn Jantz facilitates the implementation of Western Colorado’s Accountable Health Communities Model, a partnership of clinical and community organizations. Western Colorado is one of 20 regions selected by the Centers for Medicaid & Medicare Services for this initiative. The AHCM will test whether identifying an individual’s social needs and connecting them to non-clinical community services—e.g., food, stable housing and utility assistance, personal safety, transportation, and social isolation—will positively impact health care costs and outcomes. Her work also includes development of strategies to address the social determinants of health.
The Ascent: It's been six months since the Western Colorado region received a $4.5 million grant from the Centers for Medicare & Medicaid Services for its Accountable Health Communities Model efforts. Why is this important?
Jantz: When we talk about reducing health care costs and improving health outcomes, we have to talk about the social determinants of health—the social realities that affect health. About 80 percent of health outcomes are associated with factors other than health care. This is true for both people in poverty and affluent members of the community.
Tackling these big problems is daunting. AHCM gives us a clear place to start, an opportunity to shift from intent to meaningful action.
Systematic social needs screening is a concrete step in a broad cultural shift in how we think about and address social determinants of health and, ultimately, how we move the needle on health costs and outcomes. AHCM asks us to screen for social needs, provide navigation to high-risk members, and figure out solutions when our communities don’t have the appropriate services.
Participation in AHCM isn’t just about an immediate change in our communities in Western Colorado. It’s an opportunity to elevate the concerns and voices of Western Colorado in conversations at the state and federal levels about how we can better deliver and fund health services.
The Ascent: Can you share with us one highlight from the effort?
Jantz: The biggest milestone we’ve reached is establishment of a community-driven approach to leadership. We share the authority and decision-making among representative leaders from six organizations across Western Colorado: Ken Davis of Northwest Colorado Community Health Partnership; Sarah Robinson of Mesa County Health Department; Cristina Gair of West Mountain Regional Health Alliance; Rasa Kaunelis of Tri-County Health Network; Rusty Connor of Southwestern Colorado Area Health Education Center; and Laura Warner of San Juan Basin Health Department.
The Ascent: What should Western Colorado providers know about AHCM?
Jantz: Assessing patients for social needs and addressing social determinants of health is part of practicing whole-person health. Your patients will benefit, because they’ll walk away from a provider visit with information about the community-based services they need. Your staff, who may already be doing some of this work, can gain efficiency through a systematically updated list of community resources; they won’t have to research and update services on an ad hoc basis. This is the future of accountable care, and it will be essential to success in preparing for value-based payment.
The AHCM screening is an electronic tool providers can use in their practices. It asks 10 evidence-based questions about transportation, utilities, housing, food, interpersonal violence and social isolation.
When a practice submits the electronic screening data, it receives a list of appropriate, locally-vetted resources. Patients who have two or more ER visits and a social need will be connected with a navigator, who is located in their community.
This screening and referral process is akin to basic processes developed to promote the integration of behavioral health services in primary care settings. It is a simple entry point to a much broader opportunity for evidence-based, whole person health care delivery.
We’re eager to work with all primary care, behavioral health and hospital providers in Western Colorado. And we’re flexible in terms of figuring out how this can work for you. I welcome providers to contact me at (303) 638-9897 so we can discuss what we’re doing and how to get started.
The Ascent: What should community organizations know about AHCM?
Jantz: Our goal is to coordinate with referrals and services in a way that works for community organizations. To do that, we need two things from community organizations: participation in the community advisory process and feedback about the navigation and referrals that AHCM will facilitate.
We know that some community organizations may feel they are at capacity. If they’re willing to work with us to share data, we can share aggregated data with them to help them track how their interventions impact health care costs and outcomes. This information may be helpful for demonstrating program impact and seeking funding.