cmmi’s accountable health communities social screening ...cmmi’s accountable health communities...
TRANSCRIPT
The Social Interventions Research and Evaluation Network (SIREN)
CMMI’s Accountable Health Communities Social Screening Tool Webinar9.25.17
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Onlineresourcehub
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SearchableEvidenceLibrary
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ConsultationandCollaborationOpportunities
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Today’sSpeakers
KatherineVerlander,MPHDivisionofPopulationHealthIncentives&Infrastructure
CMSCMMI
AlexBillioux,MD,DPhilDivisionofPopulationHealthIncentives&Infrastructure
CMSCMMI
AccountableHealthCommunities
CMSHealth-RelatedSocialNeeds(HRSN)ScreeningTool
PresentersAlexanderBillioux,MD,DPhilKatherineR.Verlander,MPH
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AccountableHealthCommunitiesModelOverview&Structure
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• Manyofthelargestdriversofhealthcarecostsfalloutsidetheclinicalcareenvironment.
• Socialandeconomicdeterminants,healthbehaviorsandthephysicalenvironmentsignificantlydriveutilizationandcosts.
• Thereisemergingevidencethataddressinghealth-relatedsocialneedsthroughenhancedclinical-communitylinkagescanimprovehealthoutcomesandimpactcosts.
• TheAHCmodelseekstoaddresscurrentgapsbetweenhealthcaredeliveryandcommunityservices.
WhytheAccountableHealthCommunitiesModel?
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TheAccountableHealthCommunitiesModelisa5-yearmodelthattestswhethersystematicallyidentifyingandaddressingthehealth-relatedsocialneedsofcommunity-dwellingMedicareandMedicaidbeneficiariesimpactstotalhealthcarecostsandutilization.
WhatDoestheAccountableHealthCommunitiesModelTest?
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Health-RelatedSocialNeeds
CoreNeeds *Supplemental NeedsHousingInstability
UtilityNeeds
FoodInsecurity
InterpersonalViolence
Transportation
Family&SocialSupports
Education
Employment&Income
HealthBehaviors
* This list is not inclusive11
AccountableHealthCommunitiesModelStructure
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• 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
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Bridgeorganizationswill:• Screeninatleastoneofeachofthefollowingtypesofclinicaldeliverysites:a
hospital(includingtheEmergencyDepartmentandLaborandDeliveryunit);aprimarycareproviderorpractice;andaproviderofbehavioralhealthservices.
• UsethescreeningquestionsprovidedbyCMStoscreenforcorehealth-relatedsocialneeds
• Chooseanappropriatemethodtoadministerthescreeningtool
• Systematicallysubmitallinformation,includingbeneficiaryidentifiers,receivedthroughthisscreeningtooltoCMSoritscontractors
• Makethetoolavailabletoallbeneficiariesregardlessoflanguage,literacylevel,ordisabilitystatus
AHCHRSNScreening
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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
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CMSHRSNScreeningTool
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CMSHRSNScreeningTool
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CMSHRSNScreeningTool
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CMSHRSNScreeningTool
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CMSiscurrentlyclearingquestionsrecommendedbytheTEPforthefollowingsupplementalsocialneeddomains:• FinancialStrain• Employment• Education• FamilyandCommunitySupport• PhysicalActivity• SubstanceUse• MentalHealth• Disabilities
CMSHRSNScreeningTool
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• AssistanceTrackwillbeginimplementingthetoolinFebruary2018
• AlignmentTrackwillbeginimplementinginMay2018
• CMSwillmonitortheuseofthetoolandsolicitfeedbackfromAHCawardrecipients
• CMSwillweighevaluationimpactswhenconsideringanymodificationstothetool
NextStepsfortheTool
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For importantupdatesandmoreinformationontheAccountableHealthCommunitiesModelvisit:
https://innovation.cms.gov/initiatives/ahcm
ImportantAccountableHealthCommunityModelWebLinks
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HowtoconnectwithSIREN
Website: sirenetwork.ucsf.eduEmail: [email protected]: @SIREN_UCSFLinkedIn: SocialInterventionsResearch&
EvaluationNetworkFacebook: @SIRENetwork