Category Archives: Accountable Health Communities

The Opioid Crisis in Philadelphia: Killy, Dilly, Philly

By | Accountable Health Communities, Care Coordination, Opioid | No Comments

Tomorrow the city of Philadelphia will hold a major parade to celebrate Philadelphia’s title as the home of America’s National Football Champions. Many fans will be sporting “Philly Philly” and “Philly Dilly” T-shirts related to the popular Bud Light commercials – which feature a king who prefers Budweiser to all other beers – and says the cheer “dilly dilly” to those bringing the King gifts of Bud Light (calling them true “friends of the Crown” while a citizen offering a homemade beer is sent to the “pit of misery”). 1

Philadelphia also holds a national title that no one will be celebrating tomorrow – the title of the having the nation’s highest per-capita overdose rate of any major city in the nation. 2  The opioid crisis is indeed a true “dilly” of a problem (e.g. “Killy Killy”) for a city that is desperately seeking answers to the crisis. 3

Philadelphia is not the only city in America that has a “dilly” of a problem in addressing the Opioid crisis. Opioid overdose deaths in America are now equivalent to a “9/11” crisis every three weeks. 4

A Real “Pit of Misery”

Those caught in the grips of an Opioid Use Disorder are living in a real life “pit of misery”. A recent blog post by Peter Wang shares his true story of living in real pit of misery in Philadelphia as a heroin addict. 5 In this blog post Peter states: “Five years ago, I was sleeping on the streets of Philadelphia with needles hanging out of my arm. Addicted to heroin and homeless, I felt incredibly alone. I felt like there was no way I could ever do anything with my life. I didn’t think there was any way I would ever turn it around.”

Like Peter, thousands of people are living in a pit of misery caused by their Opioid use disorder. To be precise, it is estimated that 21 million people in America are living with a substance use disorder. 6

True “Friends of the Crown”

Peter Wang’s blog post includes a happy ending as Peter shares how “true friends” helped him escape his pit of misery to become a productive citizen of the “kingdom”. These “true friends” included Peter’s mother, his girlfriend, and his church. 7 Those that are helping to fight the Opioid crisis in America are indeed “true friends” of the “kingdom” of America.

Join Us in Sharing this “Philadelphia Story”

Our company eTransX has been focused on being a “true friend” for those caught in the Opioid crisis by developing information systems solutions to help solve the crisis. We want to invite the readers of this blog post to join us in this quest to fight the Opioid crisis by sharing this “Philadelphia Story” with your friends and family, and exploring ways you can personally help fight the Opioid crisis in your community.

The Philadelphia Opioid story serves as a wake-up call to every community in America that the Opioid crisis is real and growing rapidly. Now is the time to take action to solve this crisis across America.
“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead

Richard Taylor is the director of Business Development for eTransX ( an information technology company based in Brentwood TN that has been leveraging information technology to address complex challenges for over 18 years. Most recently, eTransX has teamed up with other partnering organizations to offer technology and services to help communities address the Opioid crisis.

For more details on eTransX’s Opioid solution offering go to:



1 Youtube link for the Bud Light Dilly Dilly commercial:

2 Based on 2016 opioid death statistics from the CDC,

3 Hit Hard by Opioids, Philadelphia Makes Most Radical Move Yet, Tribune News Service, Jan 24, 2018 as reported in

4 Quote by NJ Governor Chris Christie in 2017:


6 CBHSQ (2016), Results from the 2015 National Survey on Drug Use and Health (HHS) as retrieved from:


Accountable Health Communities Software

By | Accountable Health Communities, Care Coordination, Value-Based Care | No Comments

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.