Accountable Health Communities Model Opens Care Coordination Partner Opportunities

The January announcement of the Accountable Health Communities (AHC) Model by CMS gathered a lot of attention with its grant awards ranging from $1 million to $4.51 million. However, some of the steep requirements, such as screening 75,000 individuals annually or demonstrating established relationships with clinical delivery sites that have served 51% of the total number of community-dwelling beneficiaries, have likely kept many providers from applying.

Smaller providers that have made the strategic decision not to apply for the AHC Model should still take steps now to position themselves as potential partners to AHC model winners, aka bridge organizations. In fact, CMS encourages bridge organizations to create partnerships with clinical delivery sites and other organizations to reach the target number of 75,000 beneficiaries for screening and navigation.

Even if providers are not included as partners as part of the initial application, it is important to remember that each bridge organization’s performance consists of five 1-year budget periods, renewable based on satisfactory progress. This means that bridge organizations could quickly need to supplement, or replace, their original partners, if expectations are not being met.

Below are some strategic steps that providers with care coordination and navigation teams can take to be positioned as partners of choice for the bridge organizations.

Review and update your community services database
Bridge organizations are required to develop and maintain a comprehensive database, updated at least every six months, that contains information on community service providers that may be able to address the health-related social needs. Having a “scrubbed” internal list can demonstrate value as a potential partner.

Assess your technical ability to screen applicants
As mentioned above, the Accountable Health Communities Model holds bridge organizations responsible for screening 75,000 beneficiaries per year screen for health-related social needs. Although the specific screening tools has not been provided by CMS, you should access your technical ability to administer the screening tools on paper, electronically, or by trained staff.

Benchmark your care navigation team
Bridge organization that are awarded under “Tracks 2 and 3”  of the AHC are responsible for intensive community service navigation of high-risk beneficiaries with certain identified unmet health-related needs.  According to the requirements, at a minimum, AHC navigators shall have functional knowledge in: prevalent health conditions, mental health disorders, substance use disorders, interviewing techniques, care planning, cultural competency, self-advocacy, self-direction, parent/family engagement, and community-specific resources. Accessing and demonstrating these competencies now can position you as an attractive partner if and when bridge organizations requires additional care navigation assistance.

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