Accountable Health Communities Software

CMS recently announced a 5-year, $157 million program to fund Accountable Health  Communities (AHC) under the CMS Innovation Center.  The purpose of this new program is to assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.   For the first time in its history, CMS is making a significant amount of money available to help communities address the social determinants of health.  CMS has referenced several key reasons for this landmark program 1:

  • Many of the largest drivers of health care costs fall outside the clinical care environment.
  • Social and economic determinants, health behaviors and the physical environment significantly drive utilization and costs.
  • There is emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and impact costs.
  • The AHC model seeks to address current gaps between health care delivery and community services.

The foundation of the AHC model is a comprehensive screening process for health-related social needs.  These needs include but are not limited to housing needs, food insecurity, utility needs (e.g., difficulty paying utility bills), interpersonal safety (e.g., problems of intimate-partner violence, elder abuse, child maltreatment). Using the data gathered through this social needs screening process, the AHC model aims to address these underlying health-related social needs through three tiers of approaches, with each tier linked to a payment method. 2   These three tiers are referenced as Tracks 1,2,and 3 in the AHC program     The primary focus of each track is shown below:

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

While Track 2 and 3 applications were closed in May, CMS has reopened applications for Track 1 with new provisions to make it easier for communities to apply for Track 1.   Under all tracks, the AHC model will fund award recipients, called bridge organizations, to serve as “hubs”.  These bridge organizations will be responsible for coordinating AHC efforts to 2:

  • Identify and partner with clinical delivery sites
  • Conduct systematic health-related social needs screenings and make referrals
  • Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs to community service providers that might be able to address those needs
  • Align model partners to optimize community capacity to address health-related social needs

The eTransX XCare Community system offers an ideal software platform for any community that would like to pursue the implementation of a  Track 1, 2, or 3 AHC model.  Our flexible software as a service solution can support the social needs assessments and the ability to share information with the healthcare community and social service organizations.

As mentioned earlier,  Track 2 and Track 3 applications are now closed,  Track 1 applications are still open for interested communities until Nov 3, 2016.

CMS modified Track 1 application requirements for the new Track 1 funding opportunity. The modifications include: – reducing the annual number of beneficiaries applicants are required to screen from 75,000 to 53,000; and increasing the maximum funding amount per award recipient from $1 million to $1.17 million over 5 years.  CMS believes these two key modifications to Track 1 will make the program more accessible to a broader set of applicants. Applicants that previously applied to Track 1 of the AHC Model under the original FOA must re-apply using this FOA to be considered for the Model.  CMS anticipates announcing Track 1 cooperative agreement awards in the Summer of 2017. 4   eTransX would be glad to assist any Track 1 applicants in providing information related to software requirements for their Track 1 application.


Footnotes: 1 source; CMS AHC Track 1 Program Webinar slides, 09-14-16

2 ibid

3 ibid

4 ibid.

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