Fact Sheets

Accountable Health Communities (AHC) Model
Track 1 – Awareness

Accountable Health Communities (AHC) Model Track 1 – Awareness

Many of the biggest drivers of health care use and costs are beyond the scope of health care alone. Health-related social needs often are left undetected and unaddressed. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.

The Centers for Medicare & Medicaid Services (CMS) has announced an Accountable Health Communities (AHC) Model to address a critical gap between clinical care and community services in the current health care delivery system. Track 1 of the AHC model will test whether increased awareness of and referral to services addressing health-related social needs will impact total health care costs and utilization for Medicare and Medicaid beneficiaries in targeted communities.

Background

The Accountable Health Communities Model is authorized under Section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act), which established the Center for Medicare & Medicaid Innovation (Innovation Center) to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or enhancing the quality of beneficiaries’ care.

Purpose

The foundation of the Accountable Health Communities Model is universal, comprehensive screening for health-related social needs of community-dwelling Medicare, Medicaid, and dual-eligible beneficiaries accessing health care at participating clinical delivery sites. The 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 beyond medical transportation.Over a five-year performance period, CMS will implement and test a three-track model based on promising service delivery approaches. Although the Accountable Health Communities Model is a three-track model, this funding opportunity announcement is specifically for Track 1. For more information on Tracks 2 and 3, please visit the website listed below.

Accountable Health Communities Model Track 1 Structure

Funding

Funding will go to consortiums led by bridge organizations or to bridge organizations that intend to form consortiums responsible for implementing the model. CMS will support up to 12 cooperative agreements in Track 1.

The total amount of federal funds to implement Track 1 interventions over five years is up to $1.17 million for each award recipient.

CMS funds for this model cannot be used to pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by beneficiaries as a result of their participation in any of the three intervention tracks.

Evaluation

The purpose of the Accountable Health Communities evaluation is to test the impact of the Accountable Health Communities interventions on total health care costs and inpatient and outpatient health care utilization for Medicare and Medicaid beneficiaries. Track 1 of the Model will test whether community referral impacts total cost of care, emergency department visits and inpatient hospital admissions for high-risk community-dwelling Medicare and Medicaid beneficiaries. The model evaluation will include randomization for Track 1.

Eligible Applicants

Eligible applicants are community-based organizations, individual and group health care 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 with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers. Applicants from all 50 states, U.S. Territories, and the District of Columbia may apply.

Application Process

Applications to Track 1 of the model must be submitted electronically no later than 3:00 p.m. EST on November 3, 2016.

Applicants who applied to Track 1 through the previous funding opportunity announcement, CMS-1P1-17-001, must reapply to this funding opportunity announcement, CMS-1P1-17-002, by the deadline listed above to be considered for Track 1 of the model.

Applicants who applied to Track 2 and Track 3 through funding opportunity number CMS-1P1-17-001 are eligible to apply to this funding announcement for Track 1. However, successful applicants will be selected to participate in a single track only.

Organizations that did not previously apply to any tracks of the AHC Model are also eligible to apply to this funding opportunity announcement by the deadline listed above.

CMS anticipates announcing Track 1 cooperative agreement awards in the Summer of 2017. Track 2 and Track 3 cooperative agreements will be awarded, through funding opportunity number CMS-1P1-17-001 in Spring 2017.

Additional Information

For more information or to submit an application please refer to the Accountable Health Communities Funding Opportunity Announcement found at: https://innovation.cms.gov/initiatives/ahcm.

For specific questions not answered in this fact sheet or the Funding Opportunity Announcement, please send an email to AccountableHealthCommunities@cms.hhs.gov.

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[1]Beneficiaries who identify a health-related social need will be stratified based on emergency department utilization history and randomized to an intervention or control group. Beneficiaries assigned to the intervention group will receive a tailored community referral summary. Beneficiaries assigned to the control group will not receive a tailored community referral summary (developed via the AHC model); instead, they will receive usual care.