The gap between clinical care and community services is often cited as an obstacle to providing whole-person care. So many institutions have sought to find the right solution that minimizes this gap. At the CMS Center for Model Innovation (CCMI), they’re testing a new model of care that aims to do exactly this. The Accountable Health Communities (AHC) Model is a five-year test, designed to connect patients to outcome-changing services, as well as to encourage cross-system alignment.
The findings of the test so far were presented by Dawn Alley, Chief Strategy Officer at CCMI during the “Road to Equity: Structural Forum” hosted by CMS in partnership with the Office of Minority Health.
Alley transitioned into her session by explaining that CCMI has learned that data plays a role in understanding who they serve at CMS. The more they learn, the more they can provide more fruitful care opportunities. In newly introduced models, the goal is to learn how to systematically use data to better serve patient populations.
“Data driven learning is key to what we do,” Alley said during the webinar. “We can’t have a high-quality health system if we’re not providing high quality care.”
The AHC model seeks to determine if identifying and addressing Medicare and Medicaid beneficiaries’ health related social needs (HRSNs) improves quality and reduces costs.
So far, the program has 28 participating clinic sites across the U.S. that are screening patients for five major HRSNs:
· Housing instability
· Food insecurity
· Transportation problems
· Utility difficulties
· Interpersonal violence
There are also additional needs for which patients may be screened.
Participating sites follow one of two tracks: Assistance or Alignment. Depending on the tracks, the AHC model seeks to do the following:
· Screen community-dwelling beneficiaries to identify certain unmet health-related social needs (both tracks)
· Refer community-dwelling beneficiaries to community services for increased awareness (Assistance)
· Provide navigation services to assist high-risk community-dwelling beneficiaries in accessing community services (Assistance)
· Encourage alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries (Alignment)
A large chunk of promising data has arisen from sites participating in the assistance track. Within the assistance track, those reporting HRSNs and having had two or more emergency department visits in one year are “navigation-service-eligible.” This service connects beneficiaries to community services, such as food, transportation, utility or housing services. The hope is that addressing these needs directly, in conjunction with increased primary and behavioral care, will reduce use of emergency departments and help manage health conditions. Both outcomes improve care and reduce costs.
Unfortunately, researchers at CCMI have found that when identifying beneficiaries with HRSNs, they are more likely to be racial and ethnic minorities. An even bigger disparity unearthed is that beneficiaries eligible for community navigation services are also more likely to be racial and ethnic minorities.
But of course, all data must lead to action, which ideally results in a positive shift. The team working on the AHC model noticed that individuals who were navigation-service-eligible were on an upward trajectory toward increased health system utilization. After having received these services, data showed a nine percent reduction in emergency department visits among these Medicare fee-for-service beneficiaries. Alley pointed out that this would not have been possible if the data wasn’t systematically collected.
The process of the AHC model alone exemplifies how health equity can be integrated into care and payment models.
Researchers studying the model have said its benefits go further; AHC provides an objective view to care that fills large gaps often a result from implicit bias. It’s proven that delivering care without addressing social determinants of health (SDOH) can be ineffective. However, health systems may wrongly predict what SDOH patients are facing, rendering any efforts futile. Alley gave the example of one state Medicaid agency who, before joining this program, thought housing was going to be the biggest issue facing their beneficiary population. What the data collected showed was that food insecurity was a far more pressing crisis facing beneficiaries than anything else. Food insecurity has largely been the most prominent need across all the participating sites. Data helps bring these disparities to light. Alley cited another example of a provider who had been working with a patient with diabetes. When managing the patient’s case, the provider had never thought to ask about the patient’s level of food security. The AHC screening process allowed the provider to see that this was one area in which the patient was facing challenges. This would then allow them to provide more inclusive, whole-person care, for health outcomes that are attainable.
“Health systems are seeing this type of data for the first time and saying, ‘well this goes beyond what I need to do for an individual patient,’” Alley said. “This is figuring out what I can do in partnership with my community to address upstream factors and make sure these needed services are more available.”
Telehealth First Means Patient First
As Alley mentioned during the webinar, the purpose of aggregating this data is never to place more burden on patient nor provider. On the contrary, the point is to create a health landscape where equity is a reality, not just an aspiration.
The Telehealth First movement backs these principles and seeks to build upon them. Modalities such as Remote Patient Monitoring (RPM) integrate data into the workflow to pinpoint areas of concern, when the patient is too shy to say, or when the provider is too overwhelmed to notice. Data and technology present a chance to meet patients where they are and bridge a gap that has been open for so many years. Fundamentally, the movement seeks to promote telehealth as a primary option of care, so that care is always available when and where an individual may need it. Click Here to Read About the #TelehealthFirst Movement