Through this model, CMS plans to assess the efficacy of different community partnership approaches across three tracks that vary by resource intensity: the Awareness, Assistance, and Alignment tracks.
In early April, CMS selected a diverse group of 32 health care organizations to partner more closely with community services and assess performance over the course of five years, and more organizations may be added in the coming months. These organizations will serve as community hubs that bridge the gap between clinical care and social support by connecting a robust community partnership network to support Medicare and Medicaid patients.
Here are CMS's goals for the three tracks and strategies leaders need to achieve those goals—regardless of whether they will be participating in the new model.
1. The Awareness Track's goal: At a minimum, educate patients about community-based services to encourage utilization
The first and least resource-intensive track of the Accountable Health Communities Model is the Awareness Track. This track is focused on augmenting social service utilization through patient education, banking on the idea that the more patients know about existing social services, the more they will use them. In practice, this consists of disseminating literature or referring patients directly to social services. The Innovation Center will announce Awareness Track bridge organizations this summer.
Most population health leaders are already incorporating this type of patient education into existing care management responsibilities. In order to integrate patient education into the care management workflow, care teams must first be made aware of the community resources at their disposal. Some providers centralize information about community resources, organized by potential patient need, into an online resource. Other providers centralize the responsibility of making connections to community resources into a dedicated role. Regardless of which approach you take, ensure your care teams have a process for making patients aware of helpful resources in the community.