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‘Building resilience’ in community health


San Francisco Bay area-based Contra Costa Regional Medical Center and Health Centers is reinventing  its care delivery by partnering with a service provider called Health Leads to send patients to resources that address their health in a broad way, such as food and housing.

The hospital’s CEO, Anna Roth, R.N., told NEJM Catalyst about how the program works for her hospital system as part of its move toward value-based care.

 She said that “you build resilience: by surrounding providers with tools that help them meet the needs of people they’ve dedicated their lives to serving.”

“It is time we look beyond the four walls of our institutions and see how we can partner with those who have already mastered things like housing and employment…..{M}aybe the role we can play is to be strong partners for them so they can strengthen themselves.”

The Centers for Medicare and Medicaid Services   will spend as much as  $147 million in grant money starting this fall to help fund similar partnerships under a new Accountable Health Communities (AHC) model that will screen Medicare and Medicaid recipients for health-related social needs. Bridge organizations will screen and refer patients to clinical and community services.


Looking for payment models for community health


Because Cambridge Management Group has done considerable work in community/population health, including in addressing the social determinants of health, especially in the Pacific Northwest, this article in The New England Journal of Medicine caught our eyes.

The authors  of the article, headlined “Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid,” write:

“As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.

“Some encouraging innovations have emerged. Catalyzed in part by statewide all-payer delivery-system reform and the growth of value-based or shared-risk payment models, some purchasers and providers of medical care have found innovative ways to support high-value community-focused interventions. For example, Hennepin Health, a county-based Medicaid managed-care organization in Minnesota, has reduced emergency department visits by 9% by using housing and community service specialists who are part of a tightly integrated medical and social service system.”

“To accelerate the development of a scalable delivery model for addressing upstream determinants of health for Medicare and Medicaid beneficiaries, CMS recently announced a 5-year, $157 million program to test a model called Accountable Health Communities (AHC). …{T}he test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”

“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. The AHC test will improve our understanding of whether savings can materialize when upstream factors are addressed through collaboration among stakeholders who are accountable for the health and health care of their community.”

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