$157 Million in CMS Grants to Bridge Clinical Care with Social Services

Health system transformation in the U.S. took an encouraging step forward today with the announcement from CMS of a new $157 million investment in the health-related social needs of Medicare and Medicaid beneficiaries. The five-year Accountable Health Communities (AHC) initiative will fund up to 44 recipients to address the health-related social needs of a geographically defined population of beneficiaries through enhanced clinical-community linkages. According to an accompanying article published in The New England Journal of Medicine, the “AHC model reflects a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system.” Prevention Institute applauds the increased integration of clinical and behavioral health services with social services, and also strongly encourages applicants and funders to consider the role of community prevention as this initiative moves forward. Prevention Institute applauds the increased integration of clinical and behavioral health services with social services, and also strongly encourages applicants and funders to consider the role of community prevention as this initiative moves forward.

Here’s what you need to know today:

• Applicants must submit a non-binding letter of intent by February 8, 2016. The application deadline is March 31, 2016.

• The AHC model aims to identify and address beneficiaries’ health-related social needs in at least the following core areas:
-    Housing instability and quality;
-    Food insecurity;
-    Utility needs;
-    Interpersonal violence; and
-    Transportation needs.

• Applicants must have the capacity to develop and maintain relationships with clinical delivery sites and community service providers in a pre-defined geographic area in order to conduct systematic health-related social needs screenings, and to connect beneficiaries with community resources via referrals for identified unmet health-related social needs.

• The AHC model will test and implement interventions in three tracks of increasing intensity for a five-year period:  

• Track 1 – Awareness: Increase beneficiary awareness of available community services through information dissemination and referral
• Track 2 – Assistance: Assist high-risk beneficiaries with navigating and accessing community services
• Track 3 – Alignment: Encourage partner alignment to ensure that all community services are available and responsive to the needs of beneficiaries

• Eligible applicants may include community-based organizations, individual and group healthcare practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and not-for-profit local and national entities, or a consortium of partners. Applicants from all 50 states, United States territories, and the District of Columbia may apply.

• Prevention Institute and several key partners will host a webinar on this funding opportunity that features CMS Innovation Center staff on Wednesday, January 20th, from 11:30 - 1:00 PST. Registration information is forthcoming.

The full Funding Opportunity Announcement can be downloaded here. Prevention Institute will continue to track the rollout of the Accountable Health Communities Model, as it holds potential for the better integration of medical and behavioral health services with social services and supports. Yet we also recognize that a comprehensive system of health includes not only clinical and social services directed at individuals, but also community-based prevention that addresses the root causes of health in the social, physical, and economic environments—an essential approach to population health improvement not included in the federal AHC model. Our recently released brief, The Accountable Community for Health: An Emerging Model for Health System Transformation, describes the ways initiatives such as CMS’s AHC Model can be an important part of a comprehensive system of health, where clinical services, behavioral health services, social services and community supports, and community-wide efforts all work together to improve the community conditions that influence health, safety, and equity.