cmmi’s accountable health communities social screening ...cmmi’s accountable health communities...

The Social Interventions Research and Evaluation Network (SIREN)

CMMI’s Accountable Health Communities Social Screening Tool Webinar9.25.17

siren

siren

Onlineresourcehub

siren

SearchableEvidenceLibrary

siren

ConsultationandCollaborationOpportunities

siren

siren

Today’sSpeakers

KatherineVerlander,MPHDivisionofPopulationHealthIncentives&Infrastructure

CMSCMMI

AlexBillioux,MD,DPhilDivisionofPopulationHealthIncentives&Infrastructure

CMSCMMI

AccountableHealthCommunities

CMSHealth-RelatedSocialNeeds(HRSN)ScreeningTool

PresentersAlexanderBillioux,MD,DPhilKatherineR.Verlander,MPH

7

AccountableHealthCommunitiesModelOverview&Structure

8

• Manyofthelargestdriversofhealthcarecostsfalloutsidetheclinicalcareenvironment.

• Socialandeconomicdeterminants,healthbehaviorsandthephysicalenvironmentsignificantlydriveutilizationandcosts.

• Thereisemergingevidencethataddressinghealth-relatedsocialneedsthroughenhancedclinical-communitylinkagescanimprovehealthoutcomesandimpactcosts.

• TheAHCmodelseekstoaddresscurrentgapsbetweenhealthcaredeliveryandcommunityservices.

WhytheAccountableHealthCommunitiesModel?

9

TheAccountableHealthCommunitiesModelisa5-yearmodelthattestswhethersystematicallyidentifyingandaddressingthehealth-relatedsocialneedsofcommunity-dwellingMedicareandMedicaidbeneficiariesimpactstotalhealthcarecostsandutilization.

WhatDoestheAccountableHealthCommunitiesModelTest?

10

Health-RelatedSocialNeeds

CoreNeeds *Supplemental NeedsHousingInstability

UtilityNeeds

FoodInsecurity

InterpersonalViolence

Transportation

Family&SocialSupports

Education

Employment&Income

HealthBehaviors

* This list is not inclusive11

AccountableHealthCommunitiesModelStructure

12

• 32communitiesacross24States• 6intheNortheast• 7intheMidwest• 11intheSouth• 8intheWest• Urbanandrural

OverviewofBridgeOrganizationsinAssistance&AlignmentTracks

AHCBridgeOrganizations

AssistanceTrack StateAlexian BrothersNetwork Illinois

AllinaHealthSystem Minnesota

CHRISTUSSantaRosa Texas

CommunityHealthNetworkFoundation

Indiana

HackensackUniversity NewJersey

MountainStatesHealthAlliance Virginia

NevadaPrimaryCare Nevada

PartnersinHealth,Inc. WestVirginia

St.JosephsHosp.HealthCtr. NewYork

TiftCountyHosp.Authority Georgia

UTHealthSciencesCenter Texas

Yale-NewHavenHospital Connecticut

AlignmentTrack StateBaltimoreCityHealthDepartment MarylandCamdenCoalitionofHealthcareProviders NewJerseyCareNewEnglandHealthSystem RhodeIslandDanburyHospital ConnecticutDeltaHealthAlliance,Inc. MississippiDenverRegionalCouncilofGovernments ColoradoDignityHealthdba St.Joseph'sHospital&Medical

Arizona

HealthNetofWestMichigan MichiganMyHealth AccessNetwork,Inc. OklahomaOregonHealth&ScienceUniversity OregonParklandCenterforClinicalInnovation TexasPresbyterianHealthcareServices NewMexicoReadingHospital PennsylvaniaRockyMountainHMO ColoradoTheHealthCollaborative OhioTheNewYorkandPresbyterianHospital NewYorkUnitedHealthcareServiceInc. HawaiiUnitedWayofGreaterCleveland OhioUniversityofKentuckyResearchFoundation KentuckyVHQCdba HealthQualityInnovators Virginia

AssistanceTrack AlignmentTrackStart-Up PeriodMay2017-January2018• Finalizingrelationshipswithclinical

deliverysites• DevelopingSOPsforscreening, referral,

randomization,andnavigation• Hiringandtrainingstaff

Start-Up PeriodMay2017- April2018• Finalizingrelationshipswithclinical

deliverysites• DevelopingSOPsforscreening,referral,

andnavigation• Hiringandtrainingstaff• EstablishingAdvisoryBoard

ImplementationPeriodFebruary 2018-April2022• Offeringuniversalscreeningtobeneficiaries

atparticipatingsites• Providingcommunityreferralsand

navigationservicestothoseeligible

ImplementationPeriodMay2018- April 2022• Offeringuniversalscreeningtobeneficiaries

atparticipatingsites• Providingcommunityreferralsand

navigationservicestothoseeligible

AHCModelTimeline

15

Bridgeorganizationswill:• Screeninatleastoneofeachofthefollowingtypesofclinicaldeliverysites:a

hospital(includingtheEmergencyDepartmentandLaborandDeliveryunit);aprimarycareproviderorpractice;andaproviderofbehavioralhealthservices.

• UsethescreeningquestionsprovidedbyCMStoscreenforcorehealth-relatedsocialneeds

• Chooseanappropriatemethodtoadministerthescreeningtool

• Systematicallysubmitallinformation,includingbeneficiaryidentifiers,receivedthroughthisscreeningtooltoCMSoritscontractors

• Makethetoolavailabletoallbeneficiariesregardlessoflanguage,literacylevel,ordisabilitystatus

AHCHRSNScreening

16

17

Process1. Background research2. Meetings with Technical Expert Panel3. CMS finalization and permissions

Guidingprinciplesfortooldevelopment:*1. Consistentlyidentifybroadsetofneeds2. Short,accessible,consistent,andinclusive3. Evidence-basedandpracticallyinformed

CMSHRSNScreeningToolDevelopment

18* Billioux, A., K. Verlander, S. Anthony, and D. Alley. 2017. Standardized screening for health-related social needs in clinical settings: The accountable health communities screening tool. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/wp-content/uploads/2017/05/ Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf .

CMSHRSNScreeningTool

19

CMSHRSNScreeningTool

20

CMSHRSNScreeningTool

21

CMSHRSNScreeningTool

22

CMSHRSNScreeningTool

23

CMSiscurrentlyclearingquestionsrecommendedbytheTEPforthefollowingsupplementalsocialneeddomains:• FinancialStrain• Employment• Education• FamilyandCommunitySupport• PhysicalActivity• SubstanceUse• MentalHealth• Disabilities

CMSHRSNScreeningTool

24

• AssistanceTrackwillbeginimplementingthetoolinFebruary2018

• AlignmentTrackwillbeginimplementinginMay2018

• CMSwillmonitortheuseofthetoolandsolicitfeedbackfromAHCawardrecipients

• CMSwillweighevaluationimpactswhenconsideringanymodificationstothetool

NextStepsfortheTool

25

26

For importantupdatesandmoreinformationontheAccountableHealthCommunitiesModelvisit:

https://innovation.cms.gov/initiatives/ahcm

ImportantAccountableHealthCommunityModelWebLinks

27

siren

HowtoconnectwithSIREN

Website: sirenetwork.ucsf.eduEmail: siren@ucsf.eduTwitter: @SIREN_UCSFLinkedIn: SocialInterventionsResearch&

EvaluationNetworkFacebook: @SIRENetwork